Antepartum Lecture

Women’s Health
Nsg 3207

Pregnancy History
• Gravida – Number of pregnancies
Example: Gravida 3 means the patient has
had 3 pregnancies

Para – Parity – Number of pregnancies in

which the fetus has reached the age of
viability, regardless of whether or not the
fetus is born live or dead

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 Terms cont’d
• Age of Viability – 24 weeks from last
menstrual period/ or 400 grams weight of
fetus( the age at which a fetus could
survive if they were born )

• Term - Number of deliveries born

between the beginning of week 38 and the
end of week 42

Terms cont’d
• Preterm – Number of deliveries born after
week 20 gestation, but before completion
of week 37 gestation

• Post-term – Pregnancy beyond 42 weeks

gestation

Terms cont’d
• Abortion – Pregnancy ending before age
of viability. Elective and spontaneous
abortions are counted together

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 5 Digit System
• G – Gravida
• T – Term
• P – Preterm
• A – Abortions
• L - Living

Examples of 5 Digit System

• A women reports being pregnant 4 times
counting this pregnancy. One baby was
stillborn at 19 weeks. One pregnancy
resulted in twins born at 35 weeks ,and
both survived. One was born at 38 weeks
The present time she is in her 6th week of
pregnancy.
• G4 T1 P1 A1 L3

Example of 5 Digit System

• A 35 year old patient came into a
physician’s office because she had a
positive pregnancy test. She had a history
of one elective abortion at 15y/o. Then
she had a 38 week baby who died. This
pregnancy was estimated to be about
12weeks along . Her pregnancy hx is :

• G3 T1 P0 A1 L0

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 Signs of Pregnancy
• Presumptive – changes felt by the mother

• Probable – changes observed by an

examiner. This includes pregnancy tests.

• Positive – signs attributable only to the

presence of the fetus

Presumptive Signs

• Changes felt by the pregnant women

• Examples : enlarged breasts, morning
sickness

Probable Signs
• Changes felt by the examiner

• Example : Pregnancy tests both urine and

blood measure HCG

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 HCG
• Measure Human Chorionic Gonadotropin
( HCG). This maintains the corpus luteum
ensuring a continuous supply of estrogen
and progesterone to maintain the
pregnancy.
HCG - begins to rise 8-10 days after
conception and peaks at 50-70 days after
conception. Thereafter it decreases

Positive Signs
• A. Ultrasound : 5-6 weeks – presence of
fetal sac or 6 weeks showing beat of fetal
heart
• B. Doppler: 10-17 weeks - sound of fetal
heart tones
• C. Stethoscope : 17-19 weeks – sound of
fetal heart tones
• D. Palpation of fetal movement: 19-22
weeks
• E. Visible abdominal changes late in
pregnancy

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 Length of Pregnancy
• Pregnancy – 40 weeks from first day of
last menstrual period (approximately 9
months)

• Trimesters :
• 1st Trimester = 1-13 weeks
• 2ND Trimester = 14-26 weeks
• 3rd Trimester = 27-40 weeks

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 Length of Gestation
• Gestation – Number of weeks from
conception or actual time fetus has been
growing inside the mom. (approximately
38 weeks)

Difference between Length of

Pregnancy and Gestation

• Pregnancy is measured from the first day

of the last menstrual period (40 weeks)
• Gestation is measured from conception
(approximately 38 weeks)
Which is longer?
Why is it longer?

Estimated Date of Birth

• EDC – expected date of confinement

• EDB - expected date of birth

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 Nagel’s Rule
• Used to determine EDC mathmatically
• Use these steps :
1. Determine the first day of the last
menstrual period (LMP)
2. Subtract 3 months from month or add 9
months whichever is most convenient
3. Add 7 days
4. Add 1 to the year if LMP is after March

Nagel’s Rule cont’d

• Example : LMP is 2/6/07
1. Subtract 3 months/add 9 months from
date
2/6/04 + 9 = 11/6/07
2. Add 7 days
11/6/04 + 7 = 11/13/07
Answer : 11/13/07

Nagel’s Rule cont’d

• Nagel’s Rule is only approximate, so a

range is suggested for 7 days before and
7 days after the date calculated.
• Example : 11/13/07 would give a
Range of 11/6/07 to 11/20/07

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 Nagel’s Rule cont’d
• Example : LMP is 4/29/07
1. Subtract 3 months
4/29/07 – 3 months = 1/29/07
2. Add 7 days
1/29/07 + 7 days = 2/5/07
3. Add 1 to the year ( because LMP is after
March)
Answer: 2/5/08 is EDC Range of 1/29/08 to
2/12/08

Adaptation to Pregnancy

Stages of Maternal Adaptation

• Acceptance( ambivalence)
• Developing maternal role ( grief)
• Reordering personal relationships
• Changes in body image
• Fetal Attachment
• Preparing for childbirth (L&D)

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 Paternal Adaptation
• Accepting the pregnancy
• Reordering relationships
• Fetal attachment
• Preparing for childbirth
• Couvade syndrome

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 Sibling Adaptation
• Sharing spotlight. Begin interventions
during prenatal period . Do not wait until
birth to prepare sibling> changing beds,
bottle feeding, potty training etc.
• Example : Do not change out of nursery
bed the night the newborn comes home.
This is a sure disaster!

Antepartum Nursing Care

Management

• Goals : (1) To provide optimal outcome of

birth for mom newborn
(2) To promote adjustment of
family members to the newborn

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 Assessment
• Initial Visit
»Head to toe Physical
Assessment
– Lab Work: UA, H&H, CBC, Type and X
match, Rubella titre ,Glucose Tolerance,
Pap and Cervical Culture for STD’s,
Skin Tests PPD. Also blood for Alpha
Fetal Protein, and Multiple Marker Test

Lab Work Application

• H&H, CBC - Check for anemia, infections,

electrolyte imbalance, Kidney function
• Type and X match – to have blood supply
in case of emergency
• Glucose Tolerance – For Gestational
Diabetes
• Cervical Pap – for cervical cancer

Lab cont’d
• Skin Tests – TB
• UA – check for glucose, protein, WBC’s
• Alpha Fetal Protein (AFP) Low levels
associated with chromosomal and spinal
cord abnormalities
• Multiple Marker Test – low levels
associated with chromosomal
abnormalities

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 Subsequent Visits

• Monthly Visits for 1st and 2nd Trimesters

• Biweekly Visits after 28 weeks
• Weekly Visits after 36 Weeks

Frequency increases because likelihood of

complications increases in late pregnancy

Symptoms of Complications of
Pregnancy

• Persistent Excessive Vomiting

• Ketonuria
• Uterine cramping / bleeding
• Chills/ fever
• Vaginal discharge

Each Subsequent Visit

• Vital signs – including BP. 140/90
considered hypertensive in pregnancy
• Normal : 1st Trimester – same as pre-
pregnant state
2ND Trimester – drops 5-10mm
systolic and diastolic from pre-pregnant
state
3rd Trimester – Same as pre-
pregnant state

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 Each Visit cont’d
• Fetal Assessment
FHT
Note fetal movement – “quickening”
(around 20 weeks)
Fundal height - allow pt to empty
bladder, stretch paper tape from
symphysis pubis to top of uterus ( fundus),
measure in CM.

Fetal Assessment

Ultrasonography – Performed to assess fetal

age and well being. Measurements that
can be taken are : head circumference
and femur length. From these
measurements, gestational age can be
determined. Also, Visualization of heart,
spine, kidneys, and genitalia can be done.

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 Fetal Assessment con’t

Amniocentesis – A sample of amniotic fluid

can be obtained by puncturing the
abdomen. Info about genetic disorders,
congenital abnormalities and lung maturity
can be obtained from the sample.

Antepartal Teaching
• Important part of each prenatal visit to help
mom deal with changes occurring due to
pregnancy

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 Antepartal Teaching
• Nutrition:
• Well balanced diet
• 5-6 small feedings a day is better tolerated
than 3 heavy meals

Hygiene
• Usually perspire freely so may require
more frequent showers
• Avoid “hot” baths or showers to prevent
fainting
• Take showers instead of baths after “water
breaks “ or expulsion of operculum (mucus
plug )

Urinary Tract
• Infections are common. Steps to prevent
include:
• Washing hands after toileting
– Clean perineum front to back
– Use soft, white tissue
– Avoid bath oils, bubble baths
– Wear cotton crotch underpants
– Avoid tight fitting clothes

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 Urinary Tract cont’d
• Avoid tight fitting clothes
• Drink 2-3 liters of liquid /day
• Increase liquids if urine is brown or
concentrate
• Do not limit fluid intake to avoid urinary
frequency
• Void as often as needed – do not try to
retain urine for long periods of time
• Yogurt or acidophilus milk may prevent
UTI

Kegal Exercises
• Twice daily or as often as you think of it
• Helps prevent urinary incontinence
• Prepares pelvic muscles for labor

Dental Health
• Old wives tale is “ a tooth for every child”
is NOT true
• Gums may become swollen and have
excessive salivation
• Work on good hygiene and prevention of
dental caries with brushing and flossing
• Tooth or gum infections should be treated
promptly to prevent infection of the fetus

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 Physical Activity
• Generally helpful to continue present
activity level. If starting a new exercise
plan , discuss with physician.
• Avoid risky activities such as mountain
climbing or activities that she is not
accustomed to involving bouncing ,
jerking, bearing down, holding your breath
(Valsalva Maneuver)

Activity cont’d
• Take pulse - slow down if > 140.
• Stop activity if experiencing dyspnea,
dizziness, numbness, tingling, or pain of
any kind.

Posture and Body Mechanics

• Pelvic tilt exercises on hands and knees or
standing against the wall will relieve lower
back pain ( 10-12 reps)
• Use legs to bend – do not bend from the
waist
• Do not lift heavy objects

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 Rest
• Plan regular rest periods especially as the
pregnancy progresses

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 Employment
• Restrict from environments which are toxic
to the fetus and activities which require
balance or standing for long periods of
time

Clothing
• Loose , non restrictive
• Support hose should be put on before
rising from bed to prevent edema
• No tall heels or platform shoes

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 Travel
• In Normal pregnancy, travel is safe
provided conditions are sanitary and
medical care is available.
• In Hi- Risk pregnancy, travel is not
recommended after the age of viability.
• In accidents placental separation may
occur.

Car and Air travel

• Car – Wear restraints both shoulder and
lap. The straps should go above and
below the enlarged uterus. Make sure
there is no restriction of blood circulation.
• Air – Wear restraints as in car travel when
required. Take frequent walks about the
plane to prevent thrombi. Increase
hydration level.

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 Medications
• Generally ALL drugs (including OTC’s )
must be approved by a physician.

• Teratogens - means drugs that are

harmful to the fetus

• Kept a daily record of all drugs taken –

even the most common cold medicines
can be teratogenic

Substance abuse
• Cigarettes – causes growth retardation
and increased fetal morbidity and mortality
• Caffeine – limit intake
• Alcohol – abstinence
• Marijuana, heroin, cocaine – harmful to
fetus and may produce withdrawal
symptoms after birth

Sex
• Conditions which contraindicate coitus :
-More than 1 miscarriage
-Threatened abortion in 1st trimester
-Impending abortion in 2nd trimester
-Premature Rupture of Membranes
(PROM)
-Bleeding
-Abdominal Pain

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 Sex
• Old wives Tale : Sex will hurt the baby or
Mom – NOT true in normal pregnancy
• Listen to couples and allow them to
express concerns
• Many temporary problems can be handled
by changing positions, alternative methods
of satisfaction
• Continue to protect from STD’s

Nursing Care Planning for the

Antepartal Patient

Nursing Process: Assessment and

Diagnosis
• Assessment – data collected from prenatal
visits and physical assessments.
• Diagnosis – nursing diagnosis are harder
to come up with because there is no
medical illness in a normal pregnancy.
However, the patient has problems which
are a normal part of pregnancy. Nursing
plays a role in making the patient more
comfortable and well adjusted in
pregnancy. Identify areas of problems for
each individual patient.

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 Nursing Diagnosis in Antepartum
Patients
• Examples :
• Anxiety r/t fetal well being
• Altered family processes r/t mom’s labile
emotions
• Altered health maintenance r/t inadequate
nutritional intake
• Sleep pattern disturbance r/t enlarged
abdomen
• Knowledge r/t substance usage

Nursing Process: Outcomes

• Outcomes :
– Name a specific patient behavior which
will help the problem you identified. Add
a time frame which is appropriate for
accomplishing this behavior.
Example – Problem : Constipation r/t
decreased fiber intake
Outcome : Increase servings of
fiber in diet to 3x /day over the next
week.

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 Interventions
• Usually the kinds of problems and
interventions the patient exhibits will
change over the course of pregnancy.
These problems are called the
“discomforts of pregnancy”. They are
normal occurrences in pregnancy which
can usually be managed with nursing care.
They are arranged according to trimesters
so that you can change your care plan as
pregnancy progresses.

1st Trimester
Problems/Interventions
• Breast engorgement and tenderness –
wear a supportive bra and cleanse with
warm water only. Do not use any
cleansing materials which will dry, crack,
or be abrasive to the breasts.
• Urinary frequency – empty the bladder
regularly. Do Kegals and report any pain
on urination to the physician

1st Trimester
Problems/Interventions
• Fatigue – Rest as needed. Eat well
balanced diet.
• N&V – Eat crackers and sprite on waking.
Keep at bedside
• Eat 5-6 small feedings per day spreading
food intake out to prevent hypoglycemia
• Avoid gas forming or fatty foods
• Report n &v to physician if it is not gone by
2nd trimester

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 1st Trimester
Problems/Interventions
• Nasal Stuffiness – Use humidifier or saline
nose drops. No cold or flu preparations
unless physician approves them

• Leukorrhea – clear vaginal discharge.

Wear peri- pad and change as frequently
as possible to keep clean

1st Trimester
Problems/Interventions
• Mood swings – allow patient or significant
other to express concerns. May refer to
support groups or Prenatal classes.

2nd Trimester Problems

Interventions
• Skin Pigment changes – shade face,
hands, arms from the sun. Usually the
darkened areas will disappear after
pregnancy
• Palpitations – report to physicians if
accompanied by dyspnea, pulmonary
edema, or cough.

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 2nd Trimester Problems
Interventions
• Supine Hypotension – caused by the Vena
cava being compressed by the enlarged
uterus when patient lies on back. Avoid
back lying.
• Orthostatic hypotension –deep breathe,
and rise slowly from a sitting position.
Avoid sudden changes in position or warm
crowded areas.

2nd Trimester Problems

Interventions
• Food cravings – satisfy craving unless it
calls for food which is unsafe to eat or
interferes with a normal, well balanced diet

• Heartburn – limit fatty foods or foods that

readily produce gas. Avoid overeating and
lying down after meals. May use antacids,
but not Bicarbonate.

2nd Trimester Problems

Interventions
• Constipation – Exercise moderately,
increase fiber and fluid. DO NOT take
laxatives.

• Flatulence – avoid gas forming foods,

chew foods slowly.

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 2nd Trimester Problems
Interventions
• Varicose veins – avoid sitting or standing
for long periods, avoid restrictive clothing,
and constipation. Wear support hose and
elevate legs and hips at rest periods.

• Headaches – stress management. If h/a is

constant or frequent, consult physician.

2nd Trimester Problems

Interventions
• Carpal Tunnel Syndrome – elevate
affected arms to relieve edema.

• Round Ligament Pain - this ligament is

stretched as it holds up the enlarged
uterus. Rest in the horizontal position and
heat may help.

2nd Trimester Problems

Interventions
• Back ache and joint pain – wear low- heel
shoes. Apply heat, message, and rest the
affected joint. For back, use pelvic rock
exercises.

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 Discomforts of 3rd Trimester
• Dyspnea – sleep with extra pillows, avoid
overfilling stomach, stay adequately rested

• Insomnia – Relaxation, back message,

supporting body with pillows when in bed ,
warm milk or warm shower before bed
time to relax her.

Discomforts of 3rd Trimester

• Mood swings – Communication between
partners and reassure the hormones of
pregnancy alter normal emotional
responses

• Gingivitis – frequent oral hygiene,

adequate diet

Discomforts of 3rd Trimester

• Perineal discomfort – rest, good posture

• Braxton Hicks contractions – change

position or mild exercise will usually stop
them. Frequently mistaken for labor in late
pregnancy.

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 Discomforts of 3rd Trimester

• Leg cramps – dorsoflex foot until spasm

relaxes. Aluminum hydroxide gel with
each meal to eliminate the excess
phosphorus. Oral supplements of Calcium
Carbonate or calcium lactate.

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 Discomforts of 3rd Trimester
• Ankle edema – extra fluid intake, support
hose, rest with legs and hips elevated.
Contact physician if generalized edema ie.
Face, hands. Most pedal edema should
go away over night.

Recognizing Pre Term Labor

• Definition : labor at 20-37 weeks which
should be stopped to prevent preterm birth
• Call physician if :
– Contractions q 10 minutes or more for an hour
– Backache which is regular and hard for over
an hour
– Bloody spotting or fluid leaking from the
vagina

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