1: PRENATAL, INTRAPARTAL & POSTPARTUM ASSESSMENT

Anterioposterior Diameter of the Outlet

... about 13 cm

Where are you MOST likely to locate the fundal height of a pregnant woman's uterus at 22 weeks gestation: Filling the pelvis and beginning to be felt in the abdomen just above the symphysis pubis Midway between the symphysis and the umbilicus Around the level of the umbilicus Almost to the xiphoid process

3

Ultrasound can be used to detect a pregnancy as early as ____ weeks gestation. A. 4 B. 6 C. 8 D. 10

A

High Risk Factors

Abnormal presentation Multiple gestation Hydramnios Oligohydramnios Meconium stained amniotic fluid Premature rupture of membrane (PROM) Induction of labor Abruptio placentae/ placenta previa Uterine rupture Failure to progress in labor Precipitous labor (3 hrs or less) Prolapse of umbilical cord Fetal heart decelerations Postdates ( > 42 weeks) Diabetes Preeclampsia AIDS/STD- risk of additional infection and transplacental transmission

Preparation for the Physical Examination

Ask patient to provide urine specimen Patient wears examination gown Then take vital signs: BP: < 135/85; Pulse: 60-90 b/m; rate may increase 10 b/min during pregnancy. Respiration: 12-22 b/m, Temperature: 36.2 - 37.6C (97-99.6F) Head to toe examination (Review of video) General appearance, weight/weight gain, nose, mouth, neck, heart, lungs etc.

A woman is 27 weeks gestation, moderately obese and carrying twins. The nurse measures her fundal height at 30 cm. The nurse should: A. Ask another nurse to confirm her measurement for accuracy B. Realize that this may indicate intrauterine growth retardation C. Recognize this as greater than expected and refer the information to the physician D. Recognize this as a reasonable measurement for this woman

B

During the discussion with Mary Jones who is 8 weeks pregnant and is at the prenatal clinic for first PNC, she made different statements about importance of prenatal history. The different statements made by Mary Jones about prenatal history are all correct EXCEPT: A .This information will help to identify some factors that may affect my baby B .This information will help to know if my baby will survive or not C .This information will help to determine my health status before pregnancy D. This information will help to know more about my current medical problem

B

Head to toe examination (cont.)

Breast Symmetry; darker pigmentation of nipple and areola; increase noted 1st 20 wks, tingling during 1st & 3rd trimester Feeling of heaviness, striae among multipara, enlarged montgomery tubercles, colostrum after 12 wks(coming from nipples), secondary areola. Abdomen- inspect, auscultate, palpate Fetal positioning- LOA most common Fetal presentation- cephalic(head) or vertex Extremities, spine, reflexes Pelvic area Genitalia. Vagina Uterus, Ovaries Anus and Rectum Orange paper First: Helps you find out which part of the baby is in the fundus Second man- facing patients face what side the baby is on, finding the back and the extremitites Third- Feelin g the bottom , should be opposite of what is on top Fourth - facing feet, cepalic prominance and brow

Betty Sharps, a 35-year-old woman has missed her menstrual period. Her last menstrual period started at June 2 and ended June 6. Using Naegele's rule her EDB (estimated date of birth) would be: A March 11 B March 13 C March 9 D February 26

C

First Prenatal Assessment: What its all about

Current Pregnancy Past Pregnancies Gynecologic history Current Medical History Past Medical History Family and Medical History Religious /Cultural History Occupational History Partner's History Personal Information Psychosocio-cultural assessment

Ultrasound

Detects gestational sac at 4-5 weeks after LMP Detects fetal heart activity by 6 to 7 weeks Detects fetal breathing movement by 10-11weeks after LMP Biparietal diameter measured at 12-13 weeks but most accurate 14-26 weeks

Subsequent Prenatal Visits

Frequency Every 4 weeks for the first 28 weeks Then every 2 weeks from 29 to 36 weeks Then every week from 36 weeks to childbirth (40 + or - 2 weeks) CenteringPregnancy, same, but every 2 weeks from 29 to 40 weeks(come in groups0 Psychosocial assessment Physical assessment Discomforts of pregnancy Medical condition since last visit. Vital signs

Fundal height -

Fundal height - McDonald's method (during 2nd and 3rd trimester, height of fundus in cm x 8/7 = duration of pregnancy in weeks It's limitation(doesn't work with multiple babies, larger mom, babies positioning, 34 cm = 34 weeks ect Works only between 20-36 weeks) Midlline 20 weeks 36 weeks is more up cicroid process

Some terms to know

Gravida = A woman who is pregnant Gravidity = Pregnancy Nulligravida = A woman who has never been pregnant and is not currently pregnant. Primigravida = A woman who is pregnant for the first time. Multigravida = A woman who has had two or more pregnancies (has been pregnant more than once). Parity = Number of pregnancies in which the fetus or fetuses reach 20 weeks' gestation (age of viability)

Physical Assessment

Head to toe Abdominal-Assessment of uterine activity Contractions- Onset, pattern Main characteristics: Duration; Frequency; Intensity Perineum/vaginal examination(checking if membranes had ruptured, woman could be leaking Membrane status: Intact? Date/time of ROM Nitrazine test Intact- yellow-pH 5.0, olive-pH 5.5, olive green-pH 6.0 Ruptured= blue-green pH-6.5, blue-gray pH-7.0, deep blue pH-7.5 Cervical Assessment Dilatation; Effacemen(process of cervix taking over - becomes so thin cant feel it, makes bay descend easier)t; Head engagement (if 1 finger wont go in, not even that dilated)(10 cm) Presenting part-cephalic/vertex, breech Fetal descent (from station -5 to + 4) Fetal Assessment Gestational age, fetal activity Fetal response to uterine contractions (UCs) Abdominal-Assessment of uterine activity to confirm labor status Is she really having contractioons? When? Every 5? How long is duration

Cont

Hemoglobin- 12 to 16g/dl Blood type (ABO and Rh status) Complete Blood Count (CBC) Hematocrit- 38% - 47% RBC: 4.2 - 5.4 million/microliter (ul) WBC: 5000- 12,000/ul STI- Syphilis, Gonorrhea Urinalysis (u/a) - glucose, ketones, proteins, RBC, WBC, and casts. Blood Glucose Rubella Titer Hepatitis B Screen HIV screen Illicit drug screen Sickle cell screen Pap Smear There is a time wher ermom and childs blood mix. Mom could be negative though while child is positive. So anitbodies could be released attacking the foreign body, If woman is ositive with strep could affect baby and give antibodies.

Laboratory tests

Urinalysis Multiple Marker Screen (MMS) Quad screen- 15-20 weeks(congenital anomalies) Alpha-fetal protein (AFP) Elevated AFP: neural tube defects, multiple gestation, higher gestational age AFP Low: Down syndrome, Trisomy 18 Low estriol & high hCG - Down syndrome Indirect Coombs test Glucose Screen(rule out diabetes) Group B Streptococcus (GBS) (35-37 wks)

Naegele's rule

Identify the first day of last normal menstrual period (LMP). Subtract 3 months or count backwards 3 months, and then add 7 days and 1 year e.g., LMP = Dec 10, 2018 12 10 2018 -3 +7 9 17 2019 LMP = January 23, 2019

Care during Labor

Mother- Uterine Labor Contractions Uterine Palpation - Touch Frequency, duration, intensity, resting tone of uterine contractions (UC) Intrauterine pressure catheter (IUPC)( use to monitor contractions) Fetus- Fetal heart rate (FHR) Fetoscope Doppler ultrasound Fetal spiral electrode (FSE) Fetal position and presentation Inspection; Palpation- Leopold's maneuvers; Vaginal examination; Ultrasound Significant other

Estimating Due Date and Fetal Gestational Age

Naegele's rule Ultrasound Fundal height (McDonald's method) Quickening Fetal heartbeat Estimated Date of Delivery (EDD), Date of Birth (EDB); Date of Confinement (EDC

cnt

Nullipara = A woman who has not completed a pregnancy with a fetus or fetuses who have reached at least 20 weeks of gestation (who has delivered a viable fetus) Viability = Capacity to live outside of the uterus GTPAL = Acronym meaning gravity, term, preterm, abortions, living children 23-24 weeks is when most hospitals will ressussitate

Pelvic Assessment

Obstretic - smallest Station 0 - lvel of the iachial spine (crowning)

Estimating Due Date and Fetal Gestational Age

Quickening Between 16 and 20 weeks - a first fetal movement Fetal heartbeat Doppler devices Detects heart beat between 10 to 12 weeks. Fetoscope Detects heart beat as early as 16 weeks and almost always by 19 or 20 weeks Pros and Cons of the different methods Multipara woman - will ave quickening earlier Pros - Cons - make sure youre heasring the beat and not the balls

Initial Client History

Screening tool to identify negative factors that may adversely affect pregnancy and birth outcomes Assessment of adequacy of prepregnancy care Identification of existing medical conditions Baseline information Hypertension, diabtetes, cardiovascular problems

Intrapartal History and Risk Screening

Similar to prenatal visit history taking Obstetrician/nurse-midwife; pediatrician/family physician, Type of prenatal education Type of infant feeding planned Psychosocial Assessment Cultural/personal preferences Laboratory tests Confirm antenatal assessments

Definition of Terms

What is meant by the term "gravida?" "Para?" "trimesters?" Maternal Pregnancy History Traditional approach- GP Detailed approach- GTPAL G= gravidity T = term ( 37 0/7 wks) P = preterm (< 37 wks) A = abortions L = living children Traditional approach- twins= single pregnancy and single birth Contemporary- twins is single pregnancy, but 2 babies