Ricci chapter 12

Biophysical Profile (BPP)

A biophysical profile (BPP) uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being. A BPP includes ultrasound monitoring of fetal movements, fetal tone, and fetal breathing and ultrasound assessment of amniotic fluid volume with or without assessment of the fetal heart rate. A BPP is performed in an effort to identify infants who may be at risk of poor pregnancy outcome, so that additional assessments of well-being may be performed, or labor may be induced or a cesarean section performed to expedite birth. The primary objectives of the BPP are to reduce stillbirth and to detect hypoxia early enough to allow delivery in time to avoid permanent fetal damage resulting from fetal asphyxia. These parameters, together with the NST, constitute the biophysical profile. Each parameter is controlled by a different structure in the fetal brain: fetal tone by the cortex; fetal movements by the cortex and motor nuclei; fetal breathing movements by the centers close to the fourth ventricle; and the NST by the posterior hypothalamus and medulla. The amniotic fluid is the result of fetal urine volume. Some facilities do not perform an NST unless other parameters of the profile are abnormal (King et al., 2015). The BPP is based on the concept that a fetus that experiences hypoxia loses certain behavioral parameters in the reverse order in which they were acquired during fetal development (normal order of development: tone at 8 weeks; movement at 9 weeks; breathing at 20 weeks; and fetal heart rate reactivity at 24 weeks). Scoring and Interpretation The BPP is a scored test with five components, each worth two points if present. A total score of 10 is possible if the NST is used. Thirty minutes are allotted for testing, although less than 10 minutes is usually needed. The following criteria must be met to obtain a score of 2; anything less is scored as 0 (Moses, 2015c): Body movements: three or more discrete limb or trunk movements Fetal tone: one or more instances of full extension and flexion of a limb or trunk Fetal breathing: one or more fetal breathing movements of more than 30 seconds Amniotic fluid volume: one or more pockets of fluid measuring 2 cm NST: normal NST = 2 points; abnormal NST = 0 points Interpretation of the BPP score can be complicated, depending on several fetal and maternal variables. Because it is indicated as a result of a nonreassuring finding from previous fetal surveillance tests, this test can be used to quantify the interpretation, and intervention can be initiated if appropriate. A maximum score of 10 can be achieved and the test is complete once all of the variables have been observed. For the test to be judged abnormal and a score of zero awarded for the absence of fetal movement, fetal tone, or fetal breathing movements, a period of not less than 30 minutes must have elapsed. Because of the excellent sensitivity of fetal NST for fetal acidemia, it has been proposed that this acute marker alone may be used for fetal assessment in combination with the amniotic fluid volume assessment, a chronic marker. This combination, also known as the modified BPP, has been shown to have excellent false-negative rates that compare with that of the complete BPP. In addition, a recent study reported that BPP scores correlates fairly closely with the APGAR scores obtained after birth (Nisa et al., 2015). One of the important factors is the amniotic fluid volume, taken in conjunction with the results of the NST. Amniotic fluid is largely composed of fetal urine. As placental function decreases, perfusion of fetal organs, such as kidneys, decreases, and this can lead to a reduction of amniotic fluid. If oligohydramnios or decreased amniotic fluid is present, the potential exists for antepartum or intrapartum fetal compromise (Lakshmi & Jyothsna, 2015). Overall, a score of 8 to 10 is considered normal if the amniotic fluid volume is adequate. A score of 6 or below is suspicious, possibly indicating a compromised fetus; further investigation of fetal well-being is needed. Because the BPP is an ultrasonographic assessment of fetal behavior, it requires more extensive equipment and more highly trained personnel than other testing modalities. The cost is much greater than with less sophisticated tests. It permits conservative therapy and prevents premature or unnecessary intervention. There are fewer false-positive results than with the NST alone (Callahan, 2016). Nursing Management Nursing management focuses primarily on offering the client support and answering her questions. Expect to complete the NST before scheduling the biophysical profile, and explain why further testing might be needed. Tell the woman that the ultrasound will be done in the diagnostic imaging department. (Ricci 386-387) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Third trimester discomforts

A sense of well-being typically characterizes the second trimester for most women. By this time, the fatigue, nausea, and vomiting have subsided and the uncomfortable changes of the third trimester are a few months away. Not every woman experiences the same discomforts during this time, so nursing assessments and interventions must be individualized. Backache Musculoskeletal pain is a common occurrence in pregnancy and postpartum. Half of women report having back pain at some point during pregnancy. This can seriously impact the quality of life of women and have socioeconomic issues from loss days at work. The pain can be lumbar or sacroiliac. The pain may also be present only at night. Back pain is thought to be due to multiple factors, which include shifting of the center of gravity caused by the enlarging uterus, increased joint laxity due to an increase in relaxin, stretching of the ligaments (which are pain-sensitive structures), and pregnancy-related circulatory changes. Treatment is heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a good exercise program for strength and conditioning. Pregnant women may also relieve back pain by placing one foot on a stool when standing for long periods of time and placing a pillow between the legs when lying down (Plastaras & Appasamy, 2015). After exploring other reasons that might cause backache, such as uterine contractions, urinary tract infection, ulcers, or musculoskeletal back disorders, the following instructions may be helpful: Maintain correct posture, with head up and shoulders back. Wear low-heeled shoes with good arch support. When standing for long periods, place one foot on a stool or box. Use good body mechanics when lifting objects. When sitting, use foot supports and pillows behind the back. Try pelvic tilt or rocking exercises to strengthen the back (ACOG, 2015c). The pelvic tilt or pelvic rock is used to alleviate pressure on the lower back during pregnancy by stretching the lower back muscles. It can be done sitting, standing, or on all fours. To do it on all fours, the hands are positioned directly under the shoulders and the knees under the hips. The back should be in a neutral position with the head and neck aligned with the straight back. The woman then presses up with the lower back and holds this position for a few seconds, then relaxes to a neutral position. This action of pressing upward is repeated frequently throughout the day to prevent a sore back (Rigby, 2015). Leg Cramps Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. They occur primarily in the second and third trimesters and could be related to the pressure of the gravid uterus on pelvic nerves and blood vessels. During pregnancy, up to 50% of women can be affected by leg cramps, and up to 25% can be affected by restless legs syndrome (King et al., 2015). Along with lack of exercise, diet can also be a contributing factor if the woman is not consuming enough of certain minerals, such as calcium and magnesium. The sudden stretching of leg muscles may also play a role in causing leg cramps (Kondhare & Khodgire, 2015). Encourage the woman to gently stretch the muscle by dorsiflexing the foot up toward the body. Wrapping a warm, moist towel around the leg muscle can also help the muscle to relax. Advise the client to avoid stretching her legs, pointing her toes, and walking excessively. Stress the importance of wearing low-heeled shoes and support hose and arising slowly from a sitting position. If the leg cramps are due to deficiencies in minerals, the condition can be remedied by eating more foods rich in these nutrients. Also instruct the woman on calf-stretching exercises: have her stand 3 feet from the wall and lean toward it, resting her lower arms against it, while keeping her heels on the floor. This may help reduce cramping if it is done before going to bed. Elevating the legs throughout the day will help relieve pressure and minimize strain. Wearing support hose and avoiding curling the toes may help to relieve leg discomfort. Also instruct the client to avoid standing in one spot for a prolonged period or crossing her legs. If she must stand for prolonged periods, suggest that she change her position at least every 2 hours by walking or sitting to reduce the risk of leg cramps. Encourage her to drink eight 8-ounce glasses of fluid throughout the day to ensure adequate hydration. Taking daily walks can also help reduce leg cramping because ambulation improves circulation to the muscles. Varicosities of the Vulva and Legs Varicosities of the vulva and legs are associated with the increased venous stasis caused by the pressure of the gravid uterus on pelvic vessels and the vasodilation resulting from increased progesterone levels. Progesterone relaxes the vein walls, making it difficult for blood to return to the heart from the extremities; pooling can result. Genetic predisposition, inactivity, obesity, and poor muscle tone are also contributing factors. Encourage the client to wear support hose and teach her how to apply them properly. Advise her to elevate her legs above her heart while lying on her back for 10 minutes before she gets out of bed in the morning, thus promoting venous return before she applies the hose. Instruct the client to avoid crossing her legs and avoid wearing knee-high stockings. They cause constriction of leg vessels and muscles and contribute to venous stasis. Also encourage the client to elevate both legs above the level of the heart for 5 to 10 minutes at least twice a day (Fig. 12.9); to wear low-heeled shoes; and to avoid long periods of standing or sitting, frequently changing her position. If the client has vulvar varicosities, suggest she apply ice packs to the area when she is lying down. FIGURE 12.9 Woman elevating her legs while working. Hemorrhoids Hemorrhoids are varicosities of the rectum and may be external (outside the anal sphincter) or internal (above the sphincter) (ACOG, 2015d). They occur as a result of progesterone-induced vasodilation and from pressure of the enlarged uterus on the lower intestine and rectum. Hemorrhoids are more common in women with constipation, poor fluid intake or poor dietary habits, smokers, or those with a previous history of hemorrhoids (Zielinski, Searing, & Deibel, 2015). Instruct the client in measures to prevent constipation, including increasing fiber intake and drinking at least 2 L of fluid per day. Recommend the use of topical anesthetics (e.g., Preparation H®, Anusol, witch hazel compresses such as Tucks®) to reduce pain, itching, and swelling, if permitted by the health care provider. Teach the client about local comfort measures such as warm sitz baths, witch hazel compresses, or cold compresses. To minimize her risk of straining while defecating, suggest that she elevates her feet on a stool. Also encourage her to avoid prolonged sitting or standing (ACOG, 2015d). Flatulence With Bloating Flatulence and gas pain are another result of decreased gastrointestinal motility. The physiologic changes that result in constipation (reduced gastrointestinal motility and dilation secondary to progesterone's influence) may also result in increased flatulence. As the enlarging uterus compresses the bowel, it delays the passage of food through the intestines, thus allowing more time for gas to be formed by bacteria in the colon. The woman usually reports increased passage of rectal gas, abdominal bloating, or belching. Instruct the woman to avoid gas-forming foods, such as beans, cabbage, and onions, as well as foods that have a high content of white sugar. Adding more fiber to the diet, increasing fluid intake, and increasing physical exercise are also helpful in reducing flatus. In addition, reducing the amount of swallowed air, if chewing gum, will reduce gas build-up. The knee-chest position may also help with discomfort from unexpelled gas. Reducing the intake of carbonated beverages and cheese and eating mints can also help reduce flatulence during pregnancy (Almansa, De Vault, & Houghton, 2015). (Ricci 392-394) Reassure the client that these contractions are normal. Instruct the client in how to differentiate between Braxton Hicks and labor contractions. Explain that true labor contractions usually grow longer, stronger, and closer together and occur at regular intervals. Walking usually strengthens true labor contractions, whereas Braxton Hicks contractions tend to decrease in intensity and taper off. Advise the client to keep herself well hydrated and to rest in a left-side-lying position to help relieve the discomfort. Suggest that she use breathing techniques such as Lamaze techniques to ease the discomfort. (Ricci 395) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Second trimester discomforts

A sense of well-being typically characterizes the second trimester for most women. By this time, the fatigue, nausea, and vomiting have subsided and the uncomfortable changes of the third trimester are a few months away. Not every woman experiences the same discomforts during this time, so nursing assessments and interventions must be individualized. Backache Musculoskeletal pain is a common occurrence in pregnancy and postpartum. Half of women report having back pain at some point during pregnancy. This can seriously impact the quality of life of women and have socioeconomic issues from loss days at work. The pain can be lumbar or sacroiliac. The pain may also be present only at night. Back pain is thought to be due to multiple factors, which include shifting of the center of gravity caused by the enlarging uterus, increased joint laxity due to an increase in relaxin, stretching of the ligaments (which are pain-sensitive structures), and pregnancy-related circulatory changes. Treatment is heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a good exercise program for strength and conditioning. Pregnant women may also relieve back pain by placing one foot on a stool when standing for long periods of time and placing a pillow between the legs when lying down (Plastaras & Appasamy, 2015). After exploring other reasons that might cause backache, such as uterine contractions, urinary tract infection, ulcers, or musculoskeletal back disorders, the following instructions may be helpful: Maintain correct posture, with head up and shoulders back. Wear low-heeled shoes with good arch support. When standing for long periods, place one foot on a stool or box. Use good body mechanics when lifting objects. When sitting, use foot supports and pillows behind the back. Try pelvic tilt or rocking exercises to strengthen the back (ACOG, 2015c). The pelvic tilt or pelvic rock is used to alleviate pressure on the lower back during pregnancy by stretching the lower back muscles. It can be done sitting, standing, or on all fours. To do it on all fours, the hands are positioned directly under the shoulders and the knees under the hips. The back should be in a neutral position with the head and neck aligned with the straight back. The woman then presses up with the lower back and holds this position for a few seconds, then relaxes to a neutral position. This action of pressing upward is repeated frequently throughout the day to prevent a sore back (Rigby, 2015). Leg Cramps Many women experience leg cramps in pregnancy. They become more common as pregnancy progresses and are especially troublesome at night. They occur primarily in the second and third trimesters and could be related to the pressure of the gravid uterus on pelvic nerves and blood vessels. During pregnancy, up to 50% of women can be affected by leg cramps, and up to 25% can be affected by restless legs syndrome (King et al., 2015). Along with lack of exercise, diet can also be a contributing factor if the woman is not consuming enough of certain minerals, such as calcium and magnesium. The sudden stretching of leg muscles may also play a role in causing leg cramps (Kondhare & Khodgire, 2015). Encourage the woman to gently stretch the muscle by dorsiflexing the foot up toward the body. Wrapping a warm, moist towel around the leg muscle can also help the muscle to relax. Advise the client to avoid stretching her legs, pointing her toes, and walking excessively. Stress the importance of wearing low-heeled shoes and support hose and arising slowly from a sitting position. If the leg cramps are due to deficiencies in minerals, the condition can be remedied by eating more foods rich in these nutrients. Also instruct the woman on calf-stretching exercises: have her stand 3 feet from the wall and lean toward it, resting her lower arms against it, while keeping her heels on the floor. This may help reduce cramping if it is done before going to bed. Elevating the legs throughout the day will help relieve pressure and minimize strain. Wearing support hose and avoiding curling the toes may help to relieve leg discomfort. Also instruct the client to avoid standing in one spot for a prolonged period or crossing her legs. If she must stand for prolonged periods, suggest that she change her position at least every 2 hours by walking or sitting to reduce the risk of leg cramps. Encourage her to drink eight 8-ounce glasses of fluid throughout the day to ensure adequate hydration. Taking daily walks can also help reduce leg cramping because ambulation improves circulation to the muscles. Varicosities of the Vulva and Legs Varicosities of the vulva and legs are associated with the increased venous stasis caused by the pressure of the gravid uterus on pelvic vessels and the vasodilation resulting from increased progesterone levels. Progesterone relaxes the vein walls, making it difficult for blood to return to the heart from the extremities; pooling can result. Genetic predisposition, inactivity, obesity, and poor muscle tone are also contributing factors. Encourage the client to wear support hose and teach her how to apply them properly. Advise her to elevate her legs above her heart while lying on her back for 10 minutes before she gets out of bed in the morning, thus promoting venous return before she applies the hose. Instruct the client to avoid crossing her legs and avoid wearing knee-high stockings. They cause constriction of leg vessels and muscles and contribute to venous stasis. Also encourage the client to elevate both legs above the level of the heart for 5 to 10 minutes at least twice a day (Fig. 12.9); to wear low-heeled shoes; and to avoid long periods of standing or sitting, frequently changing her position. If the client has vulvar varicosities, suggest she apply ice packs to the area when she is lying down. FIGURE 12.9 Woman elevating her legs while working. Hemorrhoids Hemorrhoids are varicosities of the rectum and may be external (outside the anal sphincter) or internal (above the sphincter) (ACOG, 2015d). They occur as a result of progesterone-induced vasodilation and from pressure of the enlarged uterus on the lower intestine and rectum. Hemorrhoids are more common in women with constipation, poor fluid intake or poor dietary habits, smokers, or those with a previous history of hemorrhoids (Zielinski, Searing, & Deibel, 2015). Instruct the client in measures to prevent constipation, including increasing fiber intake and drinking at least 2 L of fluid per day. Recommend the use of topical anesthetics (e.g., Preparation H®, Anusol, witch hazel compresses such as Tucks®) to reduce pain, itching, and swelling, if permitted by the health care provider. Teach the client about local comfort measures such as warm sitz baths, witch hazel compresses, or cold compresses. To minimize her risk of straining while defecating, suggest that she elevates her feet on a stool. Also encourage her to avoid prolonged sitting or standing (ACOG, 2015d). Flatulence With Bloating Flatulence and gas pain are another result of decreased gastrointestinal motility. The physiologic changes that result in constipation (reduced gastrointestinal motility and dilation secondary to progesterone's influence) may also result in increased flatulence. As the enlarging uterus compresses the bowel, it delays the passage of food through the intestines, thus allowing more time for gas to be formed by bacteria in the colon. The woman usually reports increased passage of rectal gas, abdominal bloating, or belching. Instruct the woman to avoid gas-forming foods, such as beans, cabbage, and onions, as well as foods that have a high content of white sugar. Adding more fiber to the diet, increasing fluid intake, and increasing physical exercise are also helpful in reducing flatus. In addition, reducing the amount of swallowed air, if chewing gum, will reduce gas build-up. The knee-chest position may also help with discomfort from unexpelled gas. Reducing the intake of carbonated beverages and cheese and eating mints can also help reduce flatulence during pregnancy (Almansa, De Vault, & Houghton, 2015). (Ricci 392-394) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Alpha-Fetaprotein Analysis

Alpha-fetoprotein (AFP) is a glycoprotein produced initially by the yolk sac and fetal gut, and later predominantly by the fetal liver. In a fetus, the serum AFP level increases until approximately 14 to 15 weeks, and then falls progressively. In normal pregnancies, AFP from fetal serum enters the amniotic fluid (in microgram quantities) through fetal urination, fetal gastrointestinal secretions, and transudation across fetal membranes (amnion and placenta). About 30 years ago, elevated levels of maternal serum AFP or amniotic fluid AFP were first linked to the occurrence of fetal neural tube defects. This biomarker screening test is now recommended for all pregnant women along with other prenatal screening test depending on risk profile (ACOG, 2015b; Alexander et al., 2014). AFP is present in amniotic fluid in low concentrations between 10 and 14 weeks of gestation and can be detected in maternal serum beginning at approximately 12 to 14 weeks of gestation (Callahan, 2016). If a developmental defect is present, such as failure of the neural tube to close, more AFP escapes into amniotic fluid from the fetus. AFP then enters the maternal circulation by crossing the placenta, and the level in maternal serum can be measured. The optimal time for AFP screening is 16 to 18 weeks of gestation. Currently, ACOG recommends offering screening and diagnostic tests to all pregnant women, regardless of age or risk factors present (2015b). Correct information about gestational dating, maternal weight, race, number of fetuses, and insulin dependency is necessary to ensure the accuracy of this screening test. If incorrect maternal information is submitted or the blood specimen is not drawn during the appropriate time frame, false-positive results may occur, increasing the woman's anxiety. Subsequently, further testing might be ordered based on an inaccurate interpretation, resulting in additional financial and emotional costs to the woman. A variety of situations can lead to elevation of maternal serum AFP, including open neural tube defect, underestimation of gestational age, the presence of multiple fetuses, gastrointestinal defects, low birth weight, oligohydramnios, maternal age, diabetes, and decreased maternal weight (King et al., 2015). Lower-than-expected maternal serum AFP levels are seen when fetal gestational age is overestimated or in cases of fetal death, hydatidiform mole, increased maternal weight, maternal type 1 diabetes, and fetal trisomy 21 (Down syndrome) or trisomy 18 (Edward's syndrome) (Khalil & Coates, 2015). Measurement of maternal serum AFP is minimally invasive, requiring only a venipuncture for a blood sample. AFP has now been combined with other biomarker screening tests to determine the risk of neural tube defects and Down syndrome. Nursing management for AFP testing consists of preparing the woman for this screening test by gathering accurate information about the date of her LMP, weight, race, and gestational dating. Accurately determining the window of 16 to 18 weeks gestation will help to ensure that the test results are correct. Also explain that the test involves obtaining a blood specimen. (Ricci 381-382) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's

Amniocentesis

Amniocentesis involves a transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid for analysis. The fluid contains fetal cells that are examined to detect chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth. In addition, amniocentesis is used to confirm a fetal abnormality when other screening tests detect a possible problem. Amniocentesis is performed in the second trimester, usually between 15 and 18 weeks gestation. At this age, the amount of fluid is adequate (approximately 150 mL), and the ratio of viable to nonviable cells is the greatest (Hehir, Dalrymple, & Malone, 2015). More than 40 different chromosomal abnormalities, inborn errors of metabolism, and neural tube defects can be diagnosed with amniocentesis. It can replace a genetic probability with a diagnostic certainty, allowing the woman and her partner to make an informed decision about the option of therapeutic abortion. Amniocentesis can be performed in any of the three trimesters of pregnancy. An early amniocentesis (performed between weeks 11 and 14) is done to detect genetic anomalies. However, early amniocentesis has been associated with a high risk of spontaneous miscarriage and postprocedural amniotic fluid leakage compared with transabdominal chorionic villus screening (King et al., 2015). In the second trimester, the procedure is performed between 15 and 20 weeks to detect chromosomal abnormalities, evaluate the fetal condition when the woman is sensitized to the Rh-positive blood, diagnose intrauterine infections, and investigate amniotic fluid AFP when the MSAFP level is elevated (March of Dimes, 2015d). In the third trimester, amniocentesis is most commonly indicated to determine fetal lung maturity after the 35th week of gestation via analysis of lecithin-to-sphingomyelin ratios and to evaluate the fetal condition with Rh isoimmunization. Table 12.2 lists amniotic fluid analysis findings and their implications. Procedure Amniocentesis is performed after an ultrasound examination identifies an adequate pocket of amniotic fluid free of fetal parts, the umbilical cord, or the placenta (Fig. 12.7). The health care provider inserts a long pudendal or spinal needle, a 22-gauge, 5-inch needle, into the amniotic cavity and aspirates amniotic fluid, which is placed in an amber or foil-covered test tube to protect it from light. When the desired amount of fluid has been withdrawn, the needle is removed and slight pressure is applied to the site. If there is no evidence of bleeding, a sterile bandage is applied to the needle site. The specimens are then sent to the laboratory immediately for the cytologist to evaluate. Examining a sample of fetal cells directly produces a definitive diagnosis rather than a "best guess" diagnosis based on indirect screening tests. It is an invaluable diagnostic tool, but the risks include lower abdominal discomfort and cramping that may last up to 48 hours after the procedure, spontaneous abortion (1 in 200), maternal or fetal infection, postamniocentesis chorioamnionitis that has an insidious onset, fetal-maternal hemorrhage, leakage of amniotic fluid in 2% to 3% of women after the procedure, and higher rates of fetal loss in earlier amniocentesis procedures (<15 weeks gestation) versus later ones (Akolekar et al., 2015). Obtaining the test results may take up to 3 weeks. Women today are choosing noninvasive prenatal testing rather than undergoing invasive testing such as amniocentesis or CVS despite those tests not being 100% correct. Women with reassuring noninvasive results and normal ultrasound findings seem satisfied over the risk of procedure-related pregnancy loss (Biswas & Choolani, 2015). The number of invasive procedures has declined since the availability of noninvasive prenatal testing, and it is predicted that they will replace the more invasive procedures in the future. (Ricci 383-384) When preparing the woman for an amniocentesis, explain the procedure and its potential complications, and encourage her to empty her bladder just before the procedure to avoid the risk of bladder puncture. Inform her that a 20-minute electronic fetal monitoring strip usually is obtained to evaluate fetal well-being and obtain a baseline to compare after the procedure is completed. Obtain and record maternal vital signs. After the procedure, assist the woman to a position of comfort and administer RhoGAM intramuscularly if the woman is Rh negative to prevent potential sensitization to fetal blood. Assess maternal vital signs and fetal heart rate every 15 minutes for an hour after the procedure. Observe the puncture site for bleeding or drainage. Instruct the client to rest after returning home and remind her to report fever, leaking amniotic fluid, vaginal bleeding, or uterine contractions or any changes in fetal activity (increased or decreased) to the health care provider. FIGURE 12.7 Technique for amniocentesis: Inserting needle. When the test results come back, be available to offer support, especially if a fetal abnormality is found. Also prepare the woman and her partner for the need for genetic counseling. Trained genetic counselors can provide accurate medical information and help couples to interpret the results of the amniocentesis so they can make the decisions that are right for them as a family (Ricci 384-385) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Childbirth education classes

Childbirth education classes teach pregnant women and their support person about pregnancy, birth, and parenting. The classes are offered in local communities or online and are usually taught by certified childbirth educators. Most childbirth classes support the concept of natural childbirth (a birth without pain-relieving medications) so that the woman can be in control throughout the experience as much as possible. The classes differ in their approach to specific comfort techniques and breathing patterns. The three most common childbirth methods are the Lamaze (psychoprophylactic) method, the Bradley (partner-coached childbirth) method, and the Dick-Read (natural childbirth) method. Lamaze Method Lamaze is a psychoprophylactic ("mind prevention") method of preparing for labor and birth that promotes the use of specific breathing and relaxation techniques. Dr. Fernand Lamaze, a French obstetrician, popularized this method of childbirth preparation in the 1960s. Lamaze believed that conquering fear through knowledge and support was important. He also believed women needed to alter the perception of suffering during childbirth. This perception change would come about by learning conditioned reflexes that, instead of signaling pain, would signal the work of producing a child, and thus would carry the woman through labor awake, aware, and in control of her own body (Lamaze International, 2015). Lamaze felt strongly that all women have the right to deliver their babies with minimal or no medication while maintaining their dignity, minimizing their pain, maximizing their self-esteem, and enjoying the miracle of birth. Lamaze classes include information on toning exercises, relaxation exercises and techniques, and breathing methods for labor. The breathing techniques are used in labor to enhance relaxation and to reduce the woman's perception of pain. The goal is for women to become aware of their own comfortable rate of breathing in order to maintain relaxation and adequate oxygenation of the fetus. The following breathing techniques are an effective attention-focusing strategy to reduce pain: Paced breathing involves breathing techniques used to decrease stress responses and therefore decrease pain. This type of breathing implies self-regulation by the woman. The woman starts off by taking a cleansing breath at the onset and end of each contraction. This cleansing breath symbolizes freeing her mind from worries and concerns. This breath enhances oxygenation and puts the woman in a relaxed state. Slow-paced breathing is associated with relaxation and should be half the normal breathing rate (6 to 9 breaths per minute). This type of breathing is the most relaxed pattern and is recommended throughout labor. Abdominal or chest breathing may be used. It is generally best to breathe in through the nose and breathe out either through the nose or mouth, whichever is more comfortable for the woman. Modified-paced breathing can be used for increased work or stress during labor to increase alertness or focus attention or when slow-paced breathing is no longer effective in keeping the woman relaxed. The woman's respiratory rate increases, but it does not exceed twice her normal rate. Modified-paced breathing is a quiet upper chest breath that is increased or decreased according to the intensity of the contraction. The inhalation and the exhalation are equal. This breathing technique should be practiced during pregnancy for optimal use during labor. Patterned-paced breathing is similar to modified-paced breathing but with a rhythmic pattern. It uses a variety of patterns, with an emphasis on the exhalation breath at regular intervals. Different patterns can be used, such as 4/1, 6/1, 4/1. A 4/1 rhythm is four upper chest breaths followed by an exhalation (a sighing out of air, like blowing out a candle). Random patterns can be chosen for use as long as the basic principles of rate and relaxation are met. Couples practice these breathing patterns typically during the last few months of the pregnancy until they feel comfortable using them. Focal points (visual fixation on a designated object), effleurage (light abdominal massage by woman or partner), massage, and imagery (journey of the mind to a relaxing place) are also added to aid in relaxation. From the nurse's perspective, encourage the woman to breathe at a level of comfort that allows her to cope. Always remain quiet during the woman's periods of imagery and focal point visualization to avoid breaking her concentration. Bradley (Partner-Coached) Method The Bradley method uses various exercises and slow, controlled abdominal breathing to accomplish relaxation. Dr. Robert Bradley, a Denver-based obstetrician, advocated a completely unmedicated labor and birth experience. The Bradley method emphasizes the pleasurable sensations of childbirth, teaching women to concentrate on these sensations while "turning on" to their own bodies (Bradley Method, 2014). In 1965, Bradley wrote Husband-Coached Childbirth, which advocated the active participation of the husband as labor coach. A woman is conditioned to work in harmony with her body using breath control and deep abdominopelvic breathing to promote general body relaxation during labor. This method stresses that childbirth is a joyful, natural process and emphasizes the partner's involvement during pregnancy, labor, birth, and the early newborn period. Thus, the training techniques are directed toward the coach, not the mother. The coach is educated in massage/comfort techniques to use on the mother throughout the labor and birth process. Dick-Read Method In 1944, Grantly Dick-Read, a British obstetrician, wrote Childbirth Without Fear. He believed that the attitude of a woman toward her birthing process had a considerable influence on the ease of her labor, and he believed that fear is the primary pain-producing agent in an otherwise normal labor. He felt that fear builds a state of tension, creating an antagonistic effect on the laboring muscles of the uterus, which results in pain. A private, undisturbed, and dark environment, where women can feel safe, can promote the release of oxytocin, the hormone responsible for uterine contractions and though to promote the release of the pain-relieving hormones endorphins. When this is not achieved, women can experience fear-tension-pain syndrome, impeding labor progress and causing increased levels of pain (Westbury, 2015). Dick-Read sought to interrupt the circular pattern of fear, tension, and pain during the labor and birthing process. He promoted the belief that the degree of fear could be diminished with increased understanding of the normal physiologic response to labor (Alexander et al., 2014). p. 404 p. 405 Dick-Read believed that prenatal instruction was essential for pain relief and that emotional factors during labor interfered with the normal labor progression. The woman achieves relaxation and reduces pain by arming herself with the knowledge of normal childbirth and using abdominal breathing during contractions. (Ricci 403-405) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

chronic villus sampling

Chorionic villus sampling (CVS) is an invasive procedure involving an 18-gauge needle stick through the abdomen or passage of a suction catheter through the cervix under ultrasound guidance. This test is used to obtain a sample of the chorionic villi from the placenta for prenatal evaluation of chromosomal disorders such as Down syndrome or cystic fibrosis, enzyme deficiencies, and fetal gender determination and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay-Sachs disease (Greeley et al., 2015). Chorionic villi are fingerlike projections that cover the embryo and anchor it to the uterine lining before the placenta is developed. Because they are of embryonic origin, sampling provides information about the developing fetus. CVS can be used to detect numerous genetic disorders, with the exception of neural tube defects (Latendresse & Deneris, 2015). There has been an impetus to develop earlier prenatal diagnostic procedures so that couples can make an early decision to terminate the pregnancy if an anomaly is confirmed. Early prenatal diagnosis by CVS has been proposed as an alternative to routine amniocentesis, which carries fewer risks if done later in the pregnancy. In addition, results of CVS testing are available sooner than those of amniocentesis, usually within 48 hours. Procedure CVS is generally performed 10 to 13 weeks after the LMP. Earlier, chorionic villi may not be sufficiently developed for adequate tissue sampling and the risk of limb defects is increased (Khalil & Coates, 2015). First, an ultrasound is done to confirm gestational age and viability. Then, under continuous ultrasound guidance, CVS is performed using either a transcervical or transabdominal approach. With the transcervical approach, the woman is placed in the lithotomy position and a sterile catheter is introduced through the cervix and inserted in the placenta, where a sample of chorionic villi is aspirated. This approach requires the client to have a full bladder to push the uterus and placenta into a position that is more accessible to the catheter. A full bladder also helps in better visualization of the structures. With the transabdominal approach, an 18-gauge spinal needle is inserted through the abdominal wall into the placental tissue and a sample of chorionic villi is aspirated. Regardless of the approach used, the sample is sent to the cytogenetics laboratory for analysis. Potential complications of CVS include postprocedure vaginal bleeding and cramping (most common), hematomas, spontaneous abortion, limb abnormalities, rupture of membranes, infection, chorioamnionitis, and fetal-maternal hemorrhage (March of Dimes, 2015e). The pregnancy loss rate or procedure-related miscarriage rate is approximately 0.5% to 1.0%, which is the same rate for amniocentesis. In addition, women who are Rh negative should receive immune globulin (RhoGAM) to avoid isoimmunization (Jordan et al., 2014). Nursing Management Explain to the woman that the procedure will last about 15 minutes. An ultrasound will be done first to locate the embryo, and a baseline set of vital signs will be taken before starting. Make sure she is informed of the risks related to the procedure, including their incidence. If a transabdominal CVS procedure is planned, advise her to fill her bladder by drinking increased amounts of water. Inform her that a needle will be inserted through her abdominal wall and samples will be collected. Once the samples are collected, the needle will be withdrawn and the samples will be sent to the genetics laboratory for evaluation. p. 385 p. 386 For transcervical CVS, inform the women that a speculum will be placed into the vagina under ultrasound guidance. Then the vagina is cleaned and a small catheter is inserted through the cervix. The samples obtained through the catheter are then sent to a laboratory. After either procedure, assist the woman to a position of comfort and clean any excess lubricant or secretions from the area. Instruct her about signs to watch for and report, such as fever, cramping, and vaginal bleeding. Urge her not to engage in any strenuous activity for the next 48 hours. Assess the fetal heart rate for changes and administer RhoGAM to an unsensitized Rh-negative woman after the procedure. (Ricci 385-386) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Teaching about danger signs of pregnancy

It is important to educate the client about danger signs during pregnancy that require further evaluation. Explain that she should contact her health care provider immediately if she experiences any of the following: During the first trimester: spotting or bleeding (miscarriage), painful urination (infection), severe persistent vomiting (hyperemesis gravidarum), fever >100 °F (37.7 °C; infection), and lower abdominal pain with dizziness and accompanied by shoulder pain (ruptured ectopic pregnancy) During the second trimester: regular uterine contractions (preterm labor); pain in calf, often increased with foot flexion (blood clot in deep vein); sudden gush or leakage of fluid from vagina (premature rupture of membranes); and absence of fetal movement for more than 12 hours (possible fetal distress or demise) During the third trimester: sudden weight gain; periorbital or facial edema, severe upper abdominal pain, or headache with visual changes (gestational hypertension and/or preeclampsia); and a decrease in fetal daily movement for more than 24 hours (possible demise). Any of the previous warning signs and symptoms can also be present in this last trimester (March of Dimes, 2015a). Early Contractions One of the warning signs that should be emphasized is early contractions, which can lead to preterm birth. The woman should not confuse these early preterm contractions with Braxton Hicks contractions, which are not true labor pains because they go away when walking around or resting. They often go away when the woman goes to sleep. Braxton Hicks contractions are usually felt in the abdomen versus in the lower back with true preterm labor contractions. Signs of preterm labor that a woman may experience include contractions every 10 minutes or more frequently, change in vaginal discharge, pelvic pressure, low, dull backache, pelvic cramps, and diarrhea (Nagtalon-Ramos, 2014). All pregnant women need to be able to recognize early signs of contractions to prevent preterm labor, which is a major public health problem in the United States. Approximately 12% of all live births—or one out of nine infants —is born too soon. Our nation's rate of premature births has increased by 36% over the last 25 years. Worldwide, 15 million infants are born too soon each year (March of Dimes, 2015b). These preterm infants (born at less than 37 weeks gestation) can suffer lifelong health consequences such as intellectual disability, chronic lung disease, cerebral palsy, seizure disorders, and blindness (March of Dimes, 2015c). Preterm labor can happen to any pregnant women at any time. In many cases it can be stopped with medications if it is recognized early, before significant cervical dilation has taken place. If the woman experiences menstrual-like cramps occurring every 10 minutes accompanied by a low, dull backache, she should stop what she is doing and lie down on her left side for 1 hour and drink two or three glasses of water. If the symptoms worsen or do not subside after 1 hour, she should contact her health care provider. (Ricci 380) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

True

Preconception care should occur every time a woman of reproductive age sees a healthcare provider

Risk factors for adverse pregnancy

Preconception care is just as important as prenatal care to reduce adverse pregnancy outcomes such as maternal and infant mortality, preterm births, and low-birth-weight infants. Adverse pregnancy outcomes constitute a major public health challenge: 13% of infants are born premature; 8.3% are born with low birth weight; 1 in 33 live births have major birth defects; and 32% of women suffer pregnancy complications (CDC, 2015c). Risk factors for these adverse pregnancy outcomes are prevalent among women of reproductive age, as demonstrated by the following statistics: 10% of women smoke during pregnancy, contributing to fetal addiction to nicotine. 7.6% consume alcohol during pregnancy, leading to fetal alcohol spectrum disorder. (Ricci 363) 70% of women do not take folic acid supplements, increasing the risk of neural tube defects in the newborn. Taking folic acid reduces the incidence of neural tube defects by two thirds. 35% of women starting a pregnancy are obese, which may increase their risk of developing hypertension, diabetes, and thromboembolic disease and may increase the need for cesarean birth. 3% take prescription or over-the-counter drugs that are known teratogens (substances harmful to the developing fetus). 5% of women have preexisting medical conditions that can negatively affect pregnancy if unmanaged (CDC, 2015d). All of the preceding factors pose risks to pregnancy and could be addressed with early interventions if the woman seeks preconception health care. Specific recognized risk factors for adverse pregnancy outcomes that fall into one or more of these categories are listed in Box 12.2. The period of greatest environmental sensitivity and consequent risk for the developing embryo is between days 17 and 56 after conception. The first prenatal visit, which is usually a month or later after a missed menstrual period, may occur too late to affect reproductive outcomes associated with abnormal organogenesis secondary to poor lifestyle choices. In some cases, such as with unplanned pregnancies, women may delay seeking health care because they deny that they are pregnant. Thus, commonly used prevention practices may begin too late to avert the morbidity and mortality associated with congenital anomalies and low birth weight. A more global preventative strategy is needed to reduce the high rates of pregnancy complications in all populations. Securing international-level political priority for maternal and newborn care remains critical to accomplish the goal of better health for all families. All couples should take on the responsibility of developing their reproductive life plan and share it with their health care providers at office visits (Darmstadt, Shiffman, & Lawn, 2015). (Ricci 364) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Bottle feeding

Recent research indicates that infants who are fed formula within the first 6 months do have an increased incidence of otitis media, diabetes, asthma, atopic dermatitis, reflux, diarrhea, colic, constipation, and lower respiratory infections (Schram, 2014). It is important to inform mothers and their partners of this. Bottle-feeding an infant is not just a matter of "open, pour, and feed." Parents need information on types of formulas, preparation and storage of formula, equipment, and feeding positions. It is recommended that normal full-term infants receive conventional cow's milk-based formula; the physician should direct this choice. If the infant has a reaction (diarrhea, vomiting, abdominal pain, excessive gas) to the first formula, another formula should be tried. Sometimes a soy-based formula is substituted. In terms of preparation of formula and its use, the following guidelines should be stressed: Obtain adequate equipment (six 4-ounce bottles, eight 8-ounce bottles, and nipples). Consistency is important. Stay with a nipple that is comfortable to the infant. Frequently assess nipples for any loose pieces of rubber at the opening. Correct formula preparation is critical to the health and development of the infant. Formula is available in three forms: ready-to-feed, concentrate, and powder. Read the formula label thoroughly before mixing. Correct formula dilution is important to avoid fluid imbalances. For ready-to-use formula, use as is without dilution. For concentrated formulas, dilute with equal parts of water. For powdered formulas, mix one scoop of powder with 2 ounces of water If the water supply is safe, sterilization is not necessary. Bottles and nipples should be washed in hot, sudsy water using a bottle brush. (Ricci 408) Formula should be served at room temperature. If the water supply is questionable, water should be boiled for 5 minutes before use. Formula should not be heated in a microwave oven, because it is heated unevenly. Formula can be prepared 24 hours ahead of time and stored in the refrigerator. Teach the woman and other caretakers to feed the infant in a semi-upright position using the cradle hold in the arms. This position allows for face-to-face contact between the infant and caretaker. Advise the caretaker to hold the bottle so that the nipple is kept full of formula to prevent excessive air swallowing. Instruct the caretaker to feed the infant every 3 to 4 hours and adapt the feeding times to the infant's needs. Frequent burping of the infant (every ounce) helps prevent gas from building up in the stomach. Caution the caretaker not to prop the bottle; propping the bottle can cause choking. Bottle-feeding should mirror breast-feeding as closely as possible. While nutrition is important, so are the emotional and interactive components of feeding. Encourage the caretaker to cuddle the infant closely and position the infant so that his or her head is in a comfortable position. Also encourage communication with the infant during feedings. Nurses should know the different types of formulas available to provide advice to mothers who have made the informed choice not to breastfeed or to stop breastfeeding. (Ricci 410) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Sexual activity and sexuality

Sexuality is an important part of health and well-being. Pregnancy is characterized by intense biologic, psychological, and social changes. These changes have direct and indirect, conscious and unconscious effects on a woman's sexuality. The woman experiences dramatic alterations in her physiology, her appearance, and her body, as well as her relationships. A woman's sexual responses during pregnancy vary widely. Common symptoms such as fatigue, nausea, vomiting, breast soreness, and urinary frequency may reduce her desire for sexual intimacy. However, many women report enhanced sexual desire due to increasing levels of estrogen. Usually sexual satisfaction does not change in pregnancy compared with the prepregnancy patterns despite a decline of sexual activity during the third trimester. A discussion of expected changes in sexuality should be routinely done in order to improve couples' perception of possible sexual modifications induced by pregnancy. It is clear that, despite some difficulties related to sexual activity during pregnancy, its need and importance are recognized for both participants. Take Note! Fluctuations in sexual desire are normal and a highly individualized response throughout pregnancy. The physical and emotional adjustments of pregnancy can cause changes in body image, fatigue, mood swings, and sexual activity. The woman's changing shape, emotional status, fetal activity, changes in breast size, pressure on the bladder, and other common discomforts of pregnancy result in increased physical and emotional demands. These can produce stress on the sexual relationship of the pregnant woman and her partner. However, most women adjust well to the alterations and experience a satisfying sexual relationship. Research indicates that sexual intercourse is safe in the absence of ruptured membranes, bleeding, or placenta previa, but pregnant women engage in sex less often as the pregnancy progresses (ACOG, 2015f). Often pregnant women ask whether sexual intercourse is allowed during pregnancy or whether there are specific times when they should refrain from having sex. This is a good opportunity to educate clients about sexual behavior during pregnancy and also to ask about their expectations and individual experience related to sexuality and possible changes. It is also a good time for nurses to address the impact of the changes associated with pregnancy on sexual desire and behavior. Couples may enjoy sexual activity more because there is no fear of pregnancy and no need to disrupt spontaneity by using birth control. An increase in pelvic congestion and lubrication secondary to estrogen influence may heighten orgasm for many women. Some women have a decrease in desire because of a negative body image, fear of harming the fetus by engaging in intercourse, and fatigue, nausea, and vomiting (Boynton, 2015). Condom use can be recommended to decrease the release of prostaglandins in the semen that may stimulate contractions. A couple may need assistance to adjust to the various changes brought about by pregnancy. Reassure the women and her partner that sexual activity is permissible during pregnancy unless there is a history of any of the following: Vaginal bleeding Placenta previa Risk of preterm labor Cervical insufficiency Premature rupture of membranes Presence of infection (Rigby, 2015) Inform the couple that the fetus will not be injured by intercourse. Suggest that alternative positions may be more comfortable (e.g., woman on top, side-lying), especially during the later stages of pregnancy. Some of the physical changes in pregnancy, which can affect a couple's relationship, for example, halitosis which can result from dehydration, but can be alleviated through extra fluids and better oral hygiene. Women can have breast tenderness and skin changes that can cause them feel unattractive to their partner during pregnancy. In addition, they can be worried about increases in vaginal discharge and need to know what is normal and what can be a sign of infection. Nurses should make women feel comfortable talking about their fears, encouraging them to take pride in their changing bodies. Many women feel a particular need for closeness during pregnancy, and the woman should communicate this need to her partner (Halford, Petch, & Creedy, 2015). Emphasize to the couple that closeness and cuddling need not culminate in intercourse, and that other forms of sexual expression, such as mutual masturbation, foot massage, holding hands, kissing, and hugging can be very satisfying (Halford et al., 2015). Sex in pregnancy is normal. Research suggests that prepregnancy sexuality plays an important role in maintaining sexuality during pregnancy and postpartum (Yildiz, 2015). There are very few proven contraindications and risks to intercourse in low-risk pregnancies, and therefore, these clients should be reassured. In pregnancies complicated by placenta previa or an increased risk of preterm labor, the evidence to support abstinence is lacking, but it is a reasonable benign recommendation given the theoretical catastrophic consequences (Yeniel & Petri, 2014). Women will experience a myriad of symptoms, feelings, and physical sensations during their pregnancy. Having a satisfying sexual relationship during pregnancy is certainly possible, but it requires honest communication between partners to determine what works best for them and a good relationship with their health care provider to ensure safety (March of Dimes, 2015f). (Ricci 399-400) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

ultrasonography

Since its introduction in the late 1950s, ultrasonography has become a very useful diagnostic tool in obstetrics. Real-time scanners can produce a continuous picture of the fetus on a monitor screen. A transducer that emits high-frequency sound waves is placed on the mother's abdomen and moved to visualize the fetus (Fig. 12.6). The fetal heartbeat and any malformations in the fetus can be assessed and measurements can be made accurately from the picture on the monitor screen. Obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve pregnancy outcomes. Because the ultrasound procedure is noninvasive, it is a safe, but not evidence-based practice for low-risk women, accurate, and cost-effective tool. It provides important information about fetal activity, growth, and gestational age; assesses fetal well-being; and determines the need for invasive intrauterine tests (Maeda, 2015). There are no hard-and-fast rules as to the number of ultrasounds a woman should have during her pregnancy. A low-risk woman does not necessarily require any, but most practices do them as part of their prenatal care routine. A transvaginal ultrasound may be performed in the first trimester to confirm pregnancy, exclude ectopic (in which a fertilized egg implants somewhere other than the main cavity of the uterus) or molar (hydatidiform mole, a benign tumor that develops in the uterus) pregnancies, and confirm cardiac pulsation. A second abdominal scan may be performed at about 18 to 20 weeks to look for congenital malformations, exclude multifetal pregnancies, and verify dates and growth. A third abdominal scan may be done at around 34 weeks to evaluate fetal size, assess fetal growth, and verify placental position (Everett & Peebles, 2015). An ultrasound is used to confirm placental location during amniocentesis and to provide visualization during chorionic villus sampling (CVS). An ultrasound is also ordered whenever an abnormality is suspected. FIGURE 12.6 Ultrasound. A. Ultrasound device being applied to client's abdomen. B. View of monitor. During the past several years, ultrasound technology has advanced significantly. Now available for expecting parents is 3D/4D ultrasound imaging. Unlike traditional 2D imaging, which takes a look at the developing fetus from one angle (thus creating the "flat" image), 3D imaging takes a view of the fetus from three different angles. Software then takes these three images and merges them to produce a 3D image. Because the fourth dimension is time and movement, with 4D parents are able to watch the live movements of their fetus in 3D. Nursing management during the ultrasound procedure focuses on educating the woman about the ultrasound test and reassuring her that she will not experience any sensation from the sound waves during the test. No special client preparation is needed before performing the ultrasound, although in early pregnancy the woman may need to have a full bladder. Inform her that she may experience some discomfort from the pressure on the full bladder during the scan, but it will last only a short time. Tell the client that the conducting gel used on the abdomen during the scan may feel cold initially. (Ricci 380-381) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Breast feeding

Substantial scientific evidence exists documenting the health benefits of breast-feeding for newborns. Current evidence cited by the AAP showed improved outcomes for breast-fed infants with regard to otitis media, lower respiratory infections, gastroenteritis, atopic dermatitis, childhood asthma, childhood obesity, type 1 and type 2 diabetes, childhood leukemia, sudden infant death syndrome, and cognitive development, and for their mothers with regard to breast cancer, ovarian cancer, and type 2 diabetes. The AAP recommends that infants be breast-fed exclusively until the age 6 months, and continue to be breast-fed for a year and for as long as it is mutually desired (2012). In addition, a lack of breast-feeding has a negative impact on the health care system by increasing the number of client visits, hospital admissions, rate of obesity, and health care costs. Most researchers agree that the duration of breast-feeding is inversely associated with overweight risk. Breast-feeding is a cost-effective, natural, and effective prevention strategy for reducing childhood obesity. A recent study estimates that $13 billion a year would be saved and 1,000 deaths prevented each year if 90% of infants in the United States were exclusively breast-fed until 6 months (Office on Women's Health, 2014). Human milk provides an ideal balance of nutrients for newborns (ACOG, 2015h). Breast-feeding is advantageous for the following reasons: Human milk is digestible and economical and requires no preparation. Bonding between mother and child is promoted. Cost is less than purchasing formula. Ovulation is suppressed (however, this is not a reliable birth control method). The risk of ovarian cancer and the incidence of premenopausal breast cancer are reduced for the woman. Extra calories are used, which promotes weight loss gradually without dieting. Oxytocin is released to promote more rapid uterine involution with less bleeding. Sucking helps to develop the muscles in the infant's jaw. Absorption of lactose and minerals in the newborn is improved. The immunologic properties of breast milk help prevent infections in the baby. The composition of breast milk adapts to meet the infant's changing needs. Constipation in the baby is not a problem with adequate intake. Food allergies are less likely to develop in the breast-fed baby. The incidence of otitis media and upper respiratory infections in the infant is reduced. Breast-fed babies are less likely to be overfed, thus reducing the risk of adult obesity. Breast-fed newborns are less prone to vomiting (AAP 2015; ACOG, 2015h; American Academy of Family Physicians, 2015; Women, Infant & Children [WIC], 2015). One could say that lactation and breast-feeding are so natural that they should just happen on their own accord, but this is not the case. Learning to breast-feed takes practice, requires support from the partner, and requires dedication and patience on the part of the mother; it may be necessary to work closely with a lactation consultant to be successful and comfortable when breast-feeding. (Figure 12.14 show the different positions that may be used for breast-feeding.) Nurses can encourage breast-feeding for all mothers except those that are HIV+, and are untreated, have active tuberculosis, use illicit drugs, or take prescribed cancer chemotherapeutic agents. Breast-feeding also has some side effects. These include breast discomfort, sore nipples, mastitis, engorgement, milk stasis, vaginal dryness, and decreased libido (Alekseev, Vladimir, & Nadezhda, 2015). The most common cause of nipple pain is an improper latch and such discomfort is piercing, immediate, and short-lived, typically occurring as soon as the baby starts nursing and gradually subsiding during the feeding. Some mothers feel it is inconvenient or embarrassing, limits other activities, limits partner involvement, increases their dependency by being tied to the infant all the time, and restricts their use of alcohol or drugs. Nurses can help mothers to cope with their fear of dependency and feelings of obligation by emphasizing the positive aspects of breast-feeding and encouraging bonding experiences. Nurses can be instrumental in helping mothers prepare and continue to breastfeed after they return to work. PREPARATION FOR BREAST-FEEDING Nipple preparation is not necessary during the prenatal period unless the nipples are inverted and do not become erect when stimulated. Assess for this by placing the forefinger and thumb above and below the areola and compressing behind the nipple. If it flattens or inverts, advise the client to wear breast shields during the last 2 months of pregnancy. Breast shields exert a continuous pressure around the areola, pushing the nipple through a central opening in the inner shield (La Leche League International, 2014). The shields are worn inside the bra. Initially the shields are worn for 1 hour, and then the woman progressively increases the wearing time up to 8 hours daily. The client maintains this schedule until after childbirth, and then she wears the shield 24 hours a day until the infant latches on easily (La Leche League International, 2014). In addition, suggest that the woman wear a supportive nursing bra 24 hours a day. Encourage the woman to request a certified lactation specialist (CLS) at the hospital, if giving birth there. Lactation specialists are health care providers who specialize in the clinical management of breast-feeding. Some run their own breast-feeding support groups as well. In addition, suggest that the woman attends a breast-feeding support group (e.g., La Leche League), provide her with sources of information about infant feeding, and suggest that she reads a good reference book about lactation. All of these activities will help in her decision-making process and will be invaluable to her should she choose to breast-feed her newborn. Women returning to work can pump their breasts and store the milk in the freezer for future use. (Ricci 407-408) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

First trimester discomforts

During the first 3 months of pregnancy, the woman's body is undergoing numerous changes. Some women experience many discomforts, but others have few. These discomforts are caused by the changes taking place within the body and they pass as the pregnancy progresses. Urinary Frequency or Incontinence Urinary frequency or incontinence is common in the first trimester because the growing uterus compresses the bladder. This also is a common complaint during the third trimester, especially when the fetal head settles into the pelvis. However, the discomfort tends to improve in the second trimester, when the uterus becomes an abdominal organ and moves away from the bladder region. After infection and gestational diabetes have been ruled out as causative factors of increased urinary frequency, suggest that the woman decrease her fluid intake 2 to 3 hours before bedtime and limit her intake of caffeinated beverages. Increased voiding is normal, but encourage the client to report any pain or burning during urination. Also explain that increased urinary frequency may subside as she enters her second trimester, only to recur in the third trimester. Teach the client to perform pelvic floor muscle training exercises, formally termed Kegel exercises, to increase support of the uterus, bladder, small intestine, and rectum) throughout the day to help strengthen perineal muscle tone, thereby enhancing urinary control and decreasing the possibility of incontinence. Fatigue Fatigue plagues all pregnant women, primarily in the first and third trimesters (the highest energy levels typically occur during the second trimester), even if they get their normal amount of sleep at night. First-trimester fatigue most often is related to the many physical changes (e.g., increased oxygen consumption, increased levels of progesterone and relaxin, increased metabolic demands) and psychosocial changes (e.g., mood swings, multiple role demands) of pregnancy. Third-trimester fatigue can be caused by sleep disturbances from increased weight (many women cannot find a comfortable sleeping position due to the enlarging abdomen), physical discomforts such as heartburn, and insomnia due to mood swings, multiple role anxiety, and a decrease in exercise (Rigby, 2015). (Ricci 388) Once anemia, infection, and blood dyscrasias have been ruled out as contributing to the client's fatigue, advise her to arrange work, child care, and other demands in her life to permit additional rest periods. Work with the client to devise a realistic schedule for rest. Using pillows for support in the left-side-lying position relieves pressure on major blood vessels that supply oxygen and nutrients to the fetus when resting (Fig. 12.8). Also recommend the use of relaxation techniques, providing instructions as necessary, and suggest she increase her daily exercise level. Nausea and Vomiting It is estimated that somewhere between 70% and 80% of pregnant women experience nausea and vomiting. In the United States, this translates to approximately 4 million women. It is found more often in Western countries and urban populations, and is rare among Africans, Native Americans, Eskimos, and most Asian populations (Callahan, 2016). The problem is generally time limited, with the onset about the fifth week after the last menstrual period, a peak at 8 to 12 weeks, and resolution by 16 to 18 weeks. Despite popular use of the term morning sickness, nausea and vomiting of pregnancy persist throughout the day in the majority of affected women and has been found to be limited to the morning in less than 2% of women (Tyler & Nagtalon-Ramos, 2015). The physiologic changes that cause nausea and vomiting are unknown, but research suggests that unusually high levels of estrogen, progesterone, and hCG, and a vitamin B6 deficiency may be contributing factors. Symptoms generally last until the second trimester and are generally associated with a positive pregnancy outcome, in terms of lower rates of miscarriages, congenital malformations, and preterm births (Cunningham et al., 2014). In summary, the etiology of nausea and vomiting in pregnancy is physiologic, thus assessment of the condition focuses on severity, and the management is largely supportive. FIGURE 12.8 Using pillows for support in the side-lying position. Nausea and vomiting of pregnancy can take a physical and psychological toll on the pregnant woman, and may have an adverse effect on her partner, family members, and even co-workers. The burden it places on the woman is usually minimized, as it is considered a normal part of pregnancy, thus it may not be worthy of evaluation, diagnosis, management, and emotional support. As a result, it may not be taken seriously because it is so common and time-limited; leading some women to feel frustrated and feel guilty that they are even complaining about their symptoms. Nurses need to pick up on this, address it, and provide support for her. The goal of treatment is to improve symptoms while minimizing risks to mother and fetus. Treatment management ranges from simple dietary modifications to drug therapy. To help alleviate nausea and vomiting, advise the woman to eat small, frequent meals that are bland and low in fat (five or six times a day) to prevent her stomach from becoming completely empty. Other helpful suggestions include eating dry crackers, Cheerios, or cheese or drinking lemonade before getting out of bed in the morning and increasing her intake of foods high in vitamin B6, such as meat, poultry, bananas, fish, green leafy vegetables, peanuts, raisins, walnuts, and whole grains, or making sure she is receiving enough vitamin B6 by taking her prescribed prenatal vitamins. Pharmacologic treatment of nausea and vomiting in pregnancy is limited. The Food and Drug Administration (FDA) recently approved doxylamine-pyridoxine therapy for use in pregnancy, which seems to work fairly well based on the current reviews (Slaughter et al., 2014). Other pharmacotherapies that might be considered may include diphenhydramine (e.g., Benadryl), dimenhydrinate (e.g., Dramamine), meclinine (e.g., Antivert), prochlorperazine (e.g., Compazine), promethazine (e.g., Phenergan), or ondansetron (e.g., Zofran). Other helpful tips to deal with nausea and vomiting include the following: Get out of bed in the morning very slowly. Avoid sudden movements. Avoid triggers that stimulate or exacerbate nausea—strong food odors. Eat a high-protein snack before retiring at night to prevent an empty stomach. Take ginger (up to 1 g in divided doses daily; 250 mg capsules QID), which increases tone and peristalsis in the gastrointestinal tract. Open a window to remove odors of food being cooked. Eat more protein than carbohydrates and take in more liquids than solids. Limit intake of fluids or soups during meals (drink them between meals). Avoid fried foods and foods cooked with grease, oils, or fatty meats, because they tend to upset the stomach. Avoid highly seasoned foods such as those cooked with garlic, onions, peppers, and chili. Drink a small amount of caffeine-free carbonated beverage (ginger ale) if nauseated. Trying acupressure using a wristband has been FDA approved for nausea. Avoid wearing tight or restricting clothes, which might place increased pressure on the expanding abdomen. Avoid stress (Bope & Kellerman, 2015; Jordan et al., 2014; King et al., 2015). Breast Tenderness As a result of increased estrogen and progesterone levels, which cause the fat layer of breasts to thicken and the number of milk ducts and glands to increase during the first trimester, many women experience breast tenderness. Offering a thorough explanation to the woman about the reasons for the breast discomfort is important. Wearing a larger bra with good support can help alleviate this discomfort. Advise her to wear a supportive bra, even while sleeping. As her breasts increase in size, advise her to change her bra size to ensure adequate support. Constipation Constipation affects up to 38% of pregnancies (Verghese, Futaba, & Latthe, 2015). Increasing levels of progesterone during pregnancy lead to decreased contractility of the gastrointestinal tract, slowed movement of substances through the colon, and a resulting increase in water absorption. All of these factors lead to constipation. Lack of exercise or too little fiber or fluids in the diet can also promote constipation. In addition, the large bowel is mechanically compressed by the enlarging uterus, adding to this discomfort. The iron and calcium in prenatal vitamins can also contribute to constipation during the first and third trimesters. Explain how pregnancy exacerbates the symptoms of constipation and offer the following suggestions: Eat fresh or dried fruit daily. Eat more raw fruits and vegetables, including their skins. Eat whole-grain cereals and breads such as raisin bran or bran flakes. Participate in physical activity every day. Engage in pelvis floor exercises, stretching exercises and yoga daily Eat meals at regular intervals. Establish a time of day to defecate, and elevate feet on a stool to avoid straining. Drink six to eight glasses of water daily. Decrease intake of refined carbohydrates. Drink warm fluids on arising to stimulate bowel motility. Decrease consumption of sugary sodas. Avoid eating large amounts of cheese. If the suggestions above are ineffective, suggest that the woman use a bulk-forming laxative such as Metamucil®. Nasal Stuffiness, Bleeding Gums, Epistaxis (Nosebleeds) Increased levels of estrogen cause edema of the mucous membranes of the nasal and oral cavities. Advise the woman to drink extra water for hydration of the mucous membranes or to use a cool mist humidifier in her bedroom at night. If she needs to blow her nose to relieve nasal stuffiness, advise her to blow gently, one nostril at a time. Advise her to avoid the use of nasal decongestants and sprays. p. 391 p. 392 If a nosebleed occurs, advise the woman to loosen the clothing around her neck, sit with her head tilted forward, pinch her nostrils with her thumb and forefinger for 10 to 15 minutes, and apply an ice pack to the bridge of her nose. If the woman has bleeding gums, encourage her to practice good oral hygiene by using a soft toothbrush and flossing daily. Warm saline mouthwashes can relieve discomfort. If the gum problem persists, instruct her to see her dentist. Cravings Food craving refers to an intense desire to consume a specific food. Desires for certain foods and beverages are likely to begin during the first trimester but do not appear to reflect any physiologic need. Foods with a high sodium or sugar content often are the ones craved. At times, some women crave nonfood substances such as clay, cornstarch, laundry detergent, baking soda, soap, paint chips, dirt, ice, or wax. As explained in Chapter 11, this craving for nonfood substances, termed pica, may indicate a severe dietary deficiency of minerals or vitamins, or it may have cultural roots (Jyothi, 2015). Leukorrhea Increased vaginal discharge begins during the first trimester and continues throughout pregnancy. The physiologic changes behind leukorrhea arise from the high levels of estrogen, which cause increased vascularity and hypertrophy of cervical glands as well as vaginal cells (Cunningham et al., 2014). The result is progressively increasing vaginal secretions throughout pregnancy. Advise the woman to keep the perineal area clean and dry, washing the area with mild soap and water during her daily shower. Also recommend that she avoid wearing pantyhose and other tight-fitting nylon clothes that prevent air from circulating to the genital area. Encourage the use of cotton underwear and suggest wearing a nightgown rather than pajamas to allow for increased airflow. Also instruct the woman to avoid douching and tampon use. (Ricci 390-392) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

When preparing for a physical exam it's important to ask the woman to

Empty her bladder

Hygiene health promotion

Hygiene is a necessity for the maintenance of good health. Cleansing the skin removes dirt, bacteria, sweat, dead skin cells, and body secretions. Counsel women to wash their hands and under their fingernails frequently throughout the day in order to lower the bacterial count on both. During pregnancy a woman's sebaceous (sweat) glands become more active under the influence of hormones, and sweating is more profuse. This increase may make it necessary to use a stronger deodorant and shower more frequently. The cervical and vaginal glands also produce more secretions during pregnancy. Frequent showering helps to keep the area dry and promotes better hygiene. Encourage the use of cotton underwear to allow greater air circulation. Taking a tub bath in early pregnancy is permitted, but closer to term, when the woman's center of gravity shifts, it is safer to shower to prevent the risk of slipping. Hot Tubs and Saunas Caution pregnant women to avoid using hot tubs, saunas, whirlpools, and tanning beds during pregnancy. The heat may cause fetal tachycardia as well as raise the maternal temperature. Exposure to bacteria in hot tubs that have not been cleaned sufficiently is another reason to avoid them during pregnancy. Perineal Care The glands in the cervical and vaginal areas become more active during pregnancy secondary to hormonal influences. This increase in activity will produce more vaginal secretions, especially in the last trimester. Advise pregnant women to shower frequently and wear all-cotton underwear to minimize the effects of these secretions. Caution pregnant women not to douche, because douching can increase the risk of infection, and not to wear panty liners, which block air circulation and promote moisture. Explain that they should also avoid perfumed soaps, lotions, perineal sprays, and harsh laundry detergents to help prevent irritation and potential infection. Dental Care Physiologic changes that occur in pregnant women can adversely affect oral health. Elevations in estrogen and progesterone enhance the inflammatory response and consequently alter gingival tissue. During pregnancy, the incidence of gingivitis and periodontitis increases (Anil et al., 2015). Pregnancy is a time when a woman can be very receptive to health messaging. Pregnancy is no longer a contraindication for dental treatment; it is also a time when nurses can help clients understand that good oral health is important to a healthy pregnancy and can decrease the risk of dental caries in their children. When women see oral health as a priority for themselves, they are more likely to place a high priority on their children's oral health. Periodontal disease is a contributing factor to systemic conditions, such as heart disease, respiratory diseases, diabetes mellitus, adverse pregnancy outcomes (preterm births, low-birth-weight infants, and small-for-gestational-age infants), anemia, and stroke (Trivedi, Lal, & Singhal, 2015). Research has established that the elevated levels of estrogen and progesterone during pregnancy cause women to be more sensitive to the effects of bacterial dental plaque, which can cause gingivitis, an oral infection characterized by swollen and bleeding gums (ACOG, 2013). Brushing and flossing teeth twice daily will help reduce bacteria in the mouth. Advise the woman to visit her dentist early in the pregnancy to address any dental caries and have a thorough cleaning to prevent possible infection later in the pregnancy. Advise her to avoid exposure to x-rays by informing the hygienist of the pregnancy. If x-rays are necessary, the abdomen should be shielded with a lead apron. Researchers have reported an association between prematurity and periodontitis, an oral infection that spreads beyond the gum tissues to invade the supporting structures of the teeth. Periodontitis is characterized by bleeding gums, loss of tooth attachment, loss of supporting bone, and bad breath due to pus formation. Unfortunately, because this infection is chronic and often painless, women frequently do not realize they have it and a preterm birth can result. During pregnancy, gingivitis occurs in 35% to 100% of women, depending upon the study (Trivedi et al., 2015). Nurses should assess all pregnant women's oral health status by taking an oral health history; checking their mouths for swollen or bleeding gums, untreated dental decay, mucosal lesions, and signs of infection; and document findings in the prenatal record. Additional guidelines that the nurse should stress regarding maintaining dental health include the following: Seek professional dental care during the first trimester for assessment and care. Be reassured that oral health care is safe during pregnancy. Obtain treatment for dental pain and infection promptly during pregnancy. Brush twice daily for 2 minutes, especially before bed, with fluoridated toothpaste and rinse well. Use a soft-bristled toothbrush and be sure to brush at the gum line to remove food debris and plaque to keep gums healthy. Floss teeth daily with dental floss and rinse well afterward with plain water. Eat healthy foods, especially those high in vitamins A, C, and D, and calcium. Avoid sugary snacks. Chew sugar-free gum for 10 minutes after a meal if brushing is not possible. After vomiting, rinse your mouth immediately with baking soda (1/4 teaspoon) and warm water (1 cup) to neutralize the acid (National Maternal and Child Oral Health Resource Center, 2015). Breast Care Because the breasts enlarge significantly and become heavier throughout pregnancy, stress the need to wear a firm, supportive bra with wide straps to balance the weight of the breasts. Instruct the woman to anticipate buying a larger-sized bra about halfway through her pregnancy because of the increasing size of the breasts. Advise her to avoid using soap on the nipple area because it can be very drying. Encourage her to rinse the nipple area with plain water while bathing to keep it clean. The Montgomery glands (located in the areolar part of the nipple) secrete a lubricating substance that keeps the nipples moist and discourages growth of bacteria, so there is no need to use alcohol or other antiseptics on the nipples. If the mother has chosen to breast-feed, nipple preparation is unnecessary unless her nipples are inverted and do not become erect when stimulated. Breast shells can be worn during the last 2 months to address this issue (Alexander et al., 2014). Around week 16 of pregnancy, colostrum secretion begins, which the woman may notice as moisture in her bra. Advise the woman to place breast pads or a cotton cloth in her bra and change them frequently to prevent buildup, which may lead to excoriation. (Ricci 395-397) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Preconception care

Ideally, couples thinking about having a child should schedule a visit with their health care provider for preconception counseling to ensure that they are in the best possible state of health before pregnancy. Preconception care is the promotion of the health and well-being of a woman and her partner before pregnancy. The goal of preconception care is to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management interventions (Centers for Disease Control and Prevention [CDC], 2015a). Preconception care is advocated throughout the world as a tool for improving perinatal outcomes. Preconception care should occur any time a health care provider sees a woman of reproductive age. Primary care for all women of childbearing age by nurses should include a routine assessment of a woman's reproductive goals and planning. Women who could potentially become pregnant should be assessed for preconception risks and educated about the importance of maternal health in ensuring healthy pregnancies. Women may be motivated to address modified health risks by learning about the way their present health will affect a future pregnancy. For women not intending a pregnancy soon, preconception care should focus on contraception counseling (Callegari, Ma, & Schwartz, 2015). Personal and family history, physical examination, laboratory screening, reproductive plan, nutrition, supplements, weight, exercise, vaccinations, and injury prevention should be reviewed in all women. Encourage folic acid 400 to 800 mcg per day depending on risk profile, as well as proper diet and exercise. Women should receive the influenza vaccine if planning pregnancy during flu season; the rubella and varicella vaccines if there is no evidence of immunity to these viruses; and tetanus/diphtheria/pertussis if lacking adult vaccination. Offer specific interventions to reduce morbidity and mortality for both the woman who has been identified with chronic diseases or exposed to teratogens or illicit substances and her baby. Several interventions have been proven to effectively improve pregnancy outcome when provided as preconception care. Recent research suggests that events that occur in the uterine decidua, even before a woman knows she is pregnant, may have a significant impact on fetal growth and the outcome of pregnancy. In addition, an intact immune system optimizes placental development and function and is essential for fetal survival (Regal, Gilbert, & Burwick, 2015). New insights reveal that the early embryo is extremely sensitive to signals from gametes, trophoblastic tissue, and periconception maternal lifestyles. Also, environmental factors prior to and after conception have an enormous impact on the developing embryo and cause long-term health problems. There is a growing body of evidence that environmental factors during embryonic development can cause irreversible alteration in epigenetic markers and induce various adult diseases, such as cardiovascular, neurologic, and metabolic disorders later in life (Keytash, Jones, & Frances, 2015). With this in mind, shifting the focus on the periconception period and the very early stages of pregnancy should offer significant benefits to the health of both the mother and her infant. The overall aim should be to effectively use every pregnancy as the health care opportunity of two lifetimes (Steeggers-Theunissen & Steegers, 2015). The CDC (2015b) formulated 10 guidelines for preconception care (see Box 12.1). (Ricci 363) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nursing management for preconception

In the United States, rates of maternal mortality, unintended pregnancies, low birth weight, and preterm infants continue to rise, making the need for preconception care a priority for all nurses. Traditionally, women have thought that preconception care is a single visit made before getting pregnant; however, the maximum benefits are obtained when the woman and her partner receive care throughout her reproductive years. The nurse's role is vital in identifying risk factors and encouraging healthier behaviors that potentially improve maternal and perinatal outcomes. Preconception care involves obtaining a complete health history and physical examination of the woman and her partner. Key areas include: (Ricci 364-365) immunization status of the woman; underlying medical conditions, such as cardiovascular and respiratory problems or genetic disorders; reproductive health data, such as pelvic examinations, use of contraceptives, and STIs; sexuality and sexual practices, such as safer-sex practices and body image issues; nutrition history and present status; lifestyle practices, including occupation and recreational activities; psychosocial issues such as levels of stress and exposure to abuse and violence; medication and drug use, including use of tobacco, alcohol, over-the-counter and prescription medications, and illicit drugs; support system, including family, friends, and community. Figure 12.1 gives a sample preconception screening tool. This information provides a foundation for planning health promotion activities and education. For example, to have a positive impact on the pregnancy: ensure that the woman's immunizations are up to date; create a reproductive life plan to address and outline their reproductive needs; take a thorough history of both partners to identify any medical or genetic conditions that need treatment or a referral to specialists; identify history of STIs and high-risk sexual practices so they can be modified; complete a dietary history combined with nutritional counseling; gather information regarding exercise and lifestyle practices to encourage daily exercise for well-being and weight maintenance; stress the importance of taking folic acid to prevent neural tube defects; p. 365 p. 366 FIGURE 12.1 Sample preconception screening tool. (Used with permission. Copyright March of Dimes.) urge the woman to achieve optimal weight before a pregnancy; identify work environment and any needed changes to promote health; address substance use issues, including smoking and drugs; identify victims of violence and assist them to get help; manage chronic conditions such as diabetes and asthma; educate the couple about environmental hazards, including metals and herbs; offer genetic counseling to identify carriers; suggest the availability of support systems, if needed (Hurst & Linton, 2015; Templeton, 2015). Nurses can act as advocates and educators, creating healthy, supportive communities for women and their partners in the childbearing phases of their lives. It is important to enter into a collaborative partnership with the woman and her partner, enabling them to examine their own health and its influence on the health of their future baby. Provide information to allow the woman and her partner to make an informed decision about having a baby, but keep in mind that this decision rests solely with the couple. (Ricci 365-367) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

First prenatal visit

Once a pregnancy is suspected and, in some cases, tentatively confirmed by a home pregnancy test, the woman should seek prenatal care to promote a healthy outcome. Although the most opportune window (preconception) for improving pregnancy outcomes may be missed, appropriate nursing management starting at conception and continuing throughout the pregnancy can have a positive impact on the health of pregnant women and their unborn children. The assessment process begins at this initial prenatal visit and continues throughout the pregnancy. The initial visit is an ideal time to screen for factors that might place the woman and her fetus at risk for problems such as preterm delivery. The initial visit also is an optimal time to begin educating the client about changes that will affect her life. Prenatal care can be delivered in one of the two methods: individually or in a group format termed centering. The first method is the traditional model whereby a pregnant woman sees her health care provider at specified interims throughout her pregnancy and all visits occur on a one-to-one basis. The centering pregnancy model of group prenatal care involves groups of up to a dozen women in similar gestational ages meeting with their health care provider for 10 sessions of approximately 1.5 to 2 hours each. The centering group method has been theorized to produce better birth outcomes than traditional individually delivered prenatal care due to increased client-provider interaction, increased social support, and greater perceived empowerment (Tracy, 2014). See Evidence-Based Practice 12.1. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently issued recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Specific recommendations for diagnosing hyperglycemic disorders in pregnancy include the following: At the first prenatal visit, measure fasting plasma glucose, HbA1c, or random plasma glucose of all women or all high-risk women based on her risk factors, weight status, and family history. Thresholds for diagnosis of overt diabetes during pregnancy are shown in Box 12.3. If glucose testing is not diagnostic of overt diabetes, the woman should be tested for gestational diabetes from 24 to 28 weeks of gestation with a 2-hour 75-g oral glucose tolerance test (American Diabetes Association [ADA], 2015). Given our society's poor food choices, sedentary tendencies, obesity, increasing life stresses, and the increasing immigration of high-risk populations (Hispanic, African American, Southeast Asian, Arab, Afro-Caribbean, Mediterranean, and Native American), the incidence of gestational diabetes is growing. The American College of Obstetricians and Gynecologists (ACOG), the American Diabetes Association (ADA), and the World Health Organization (WHO) have all recommended screening at the first prenatal visit for women who are over 25 years old, overweight, have polycystic ovary syndrome, history of gestational diabetes, and a positive family history of diabetes (Satyan et al., 2015). Global guidelines for screening, diagnosis, and classification have been established, and offer the potential to stop the cycle of diabetes and obesity caused by hyperglycemia in pregnancy. Normoglycemia is the goal in all aspects of pregnancy and offers the benefits of decreased short-term and long-term complications of diabetes. (Ricci 367-368) Counseling and education of the pregnant woman and her partner are critical to ensure healthy outcomes for mother and her infant. Pregnant women and their partners frequently have questions, misinformation, or misconceptions about what to eat, weight gain, physical discomforts, drug and alcohol use, sexuality, and the birthing process. The nurse needs to allow time to answer questions and provide anticipatory guidance during the pregnancy and to make appropriate community referrals to meet the needs of these clients. To address these issues and foster the overall well-being of pregnant women and their fetuses, specific national health goals have been established (see Healthy People 2020). (Ricci 368) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Health history components

Reason for Seeking Care The woman commonly comes for prenatal care based on the suspicion that she is pregnant. She may report that she has missed her menstrual period or has had a positive result on a home pregnancy test. Ask the woman for the date of her last normal menstrual period (LMP). Also ask about any presumptive or probable signs of pregnancy that she might be experiencing. Typically a urine or blood test to check for evidence of human chorionic gonadotropin (hCG) is done to confirm the pregnancy. Past History Ask about the woman's past medical and surgical history. This information is important because conditions that the woman experienced in the past (e.g., urinary tract infections) may recur or be exacerbated during pregnancy. Also, chronic illnesses, such as diabetes or heart disease, can increase the risk for complications during pregnancy for the woman and her fetus. Ask about any history of allergies to medications, foods, or environmental substances. Ask about any mental health problems, such as depression or anxiety. Gather similar information about the woman's family and her partner. The woman's personal history also is important. Ask about her occupation, possible exposure to teratogens, exercise and activity level, recreational patterns (including the use of substances such as alcohol, tobacco, and drugs), use of alternative and complementary therapies, sleep patterns, nutritional habits, and general lifestyle. Each of these may have an impact on the outcome of the pregnancy. For example, if the woman smokes during pregnancy, nicotine in the cigarettes causes vasoconstriction in the mother, leading to reduced placental perfusion. As a result, the newborn may be small for gestational age. The newborn will also go through nicotine withdrawal soon after birth. In addition, no safe level of alcohol ingestion in pregnancy has been determined. Many fetuses exposed to heavy alcohol levels during pregnancy develop fetal alcohol syndrome, a collection of deformities and disabilities. Reproductive History The woman's reproductive history includes a menstrual, obstetric, and gynecologic history. Typically, this history begins with a description of the woman's menstrual cycle, including her age at menarche, number of days in her cycle, typical flow characteristics, and any discomfort experienced. The use of contraception also is important, including when the woman last used any contraception. Establishing an accurate due date is one of the most important assessments for a pregnant woman, one that has both social and medical significance. For women and their families, this estimated due date (EDD) represents the long-awaited birthday of their child and is a time frame around which many economic and social activities are planned. This end point date provides guidance for the timing of specific maternal and fetal testing throughout pregnancy, gauges fetal growth parameters, and provides well-established timelines for specific interventions in the management of prenatal complications. In fact, critical decisions, such as preterm labor management, timing of postdate induction of labor, and identification of fetal growth restriction (FGR), are all based on the presumed gestational age of the fetus, which is calculated backwards from the EDD (Bond, 2015). (Ricci 372) Ask the woman the date of her LMP to determine the estimated or EDD. Several methods may be used to estimate the date of birth. Nagele's rule can be used to establish the EDD (Box 12.4). Using this rule, subtract 3 months from the month of her LMP and then add 7 days to the first day of the LMP. Then correct the year by adding 1 to it where necessary. An alternative way is to add 7 days and then add 9 months = year where needed. This date has a margin of error of plus or minus 2 weeks. For instance, if a woman reports that her LMP was October 14, 2015, you would subtract 3 months (July) and add 7 days (21), then add 1 year (2016). The woman's EDD is July 21, 2016. Because of the normal variations in women's menstrual cycles, differences in the normal length of gestation among ethnic groups, and errors in dating methods, there is no such thing as an exact due date. In general, a birth 2 weeks before or 2 weeks after the EDD is considered normal. Nagele's rule is less accurate if the woman's menstrual cycles are irregular, if the woman conceives while breast-feeding or before her regular menstrual cycle is established after childbirth, if she is ovulating although she is amenorrheic, or after she discontinues oral contraceptives (Schuiling & Likis, 2016). A gestational or birth calculator or wheel can also be used to calculate the due date (Fig. 12.3). Some practitioners use ultrasound to more accurately determine the gestational age and date the pregnancy. Ultrasound is typically the most accurate method of dating a pregnancy. Typically, an obstetric history provides information about the woman's past pregnancies, including any problems encountered during the pregnancy, labor, birth, and postpartum. Such information can provide clues to problems that might develop in the current pregnancy. Some common terms used to describe and document an obstetric history include gravid, gravida, gravida I (primigravida), gravida II (secundigravida), multigravida, and para (Table 12.1). FIGURE 12.3 EDD using a birth wheel. The first day of the woman's last normal menstrual period was October 1. Using the birth wheel, her EDD would be approximately July 8 of the following year. (Used with permission. Copyright March of Dimes, 2015.) Other systems may be used to document a woman's obstetric history. These systems often break down the category of para more specifically (Box 12.5). Information about the woman's gynecologic history is important. Ask about any reproductive tract surgeries the woman has undergone. For example, surgery on the uterus may affect its ability to contract effectively during labor. A history of tubal pregnancy increases the woman's risk for another tubal pregnancy. Also ask about safe-sex practices and any history of STIs. (Ricci 372-373) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nonstress test

The nonstress test (NST) is the most common method of prenatal testing used in practice today. The NST provides an indirect measurement of uteroplacental function. Unlike the fetal movement counting done by the mother alone, this procedure requires specialized equipment and trained personnel. The basis for the NST is that the normal fetus produces characteristic fetal heart rate patterns in response to fetal movements. In the healthy fetus there is an acceleration of the fetal heart rate with fetal movement. Currently, an NST is recommended twice weekly (after 28 weeks of gestation) for clients with diabetes and other high-risk conditions, such as IUGR, preeclampsia, post-term pregnancy, renal disease, and multifetal pregnancies (Cunningham et al., 2014). NST is a noninvasive test that requires no initiation of contractions. It is quick to perform and there are no known side effects. Procedure Before the procedure, the client eats a meal to stimulate fetal activity. Then she is placed in the left lateral recumbent position to avoid supine hypotension syndrome. An external electronic fetal monitoring device is applied to her abdomen. The device consists of two belts, each with a sensor. One of the sensors records uterine activity, while the second sensor records fetal heart rate. The client is handed an "event marker" with a button that she pushes every time she perceives fetal movement. When the button is pushed, the fetal monitor strip is marked to identify that fetal movement has occurred. The procedure usually lasts 20 to 30 minutes. Nursing Management Prior to the NST, explain the testing procedure and have the woman empty her bladder. Position her in a semi-Fowler's position and apply the two external monitor belts. Document the date and time the test is started, client information, the reason for the test, and the maternal vital signs. Obtain a baseline fetal monitor strip over 15 to 30 minutes. During the test, observe for signs of fetal activity with a concurrent acceleration of the fetal heart rate. Interpret the NST as reactive or nonreactive. A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. A nonreactive test has been correlated with a higher incidence of fetal distress during labor, fetal mortality, and IUGR. Additional testing, such as a biophysical profile, should be considered (King et al., 2015). After the NST procedure, assist the woman off the table, provide her with fluids, and allow her to use the restroom. Typically the health care provider discusses the results with the woman at this time. Provide teaching about signs and symptoms to report. If serial NSTs are being done, schedule the next testing session. (Ricci 386) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Pelvic examination

The pelvic examination provides information about the internal and external reproductive organs. In addition, it aids in assessing some of the presumptive and probable signs of pregnancy and allows for determination of pelvic adequacy. During the pelvic examination, remain in the examining room to assist the health care provider with any specimen collection, fixation, and labeling. Also provide comfort and emotional support for the woman, who might be anxious. Throughout the examination, explain what is happening and why, and answer any questions as necessary. EXTERNAL GENITALIA After the client is placed in the lithotomy position and draped appropriately, the external genitalia are inspected visually. They should be free from lesions, discharge, hematomas, varicosities, and inflammation upon inspection. A culture for STIs may be collected at this time. INTERNAL GENITALIA Next, the internal genitalia are examined via a speculum. The cervix should be smooth, long, thick, and closed. Because of increased pelvic congestion, the cervix will be softened (Goodell's sign), the uterine isthmus will be softened (Hegar's sign), and there will be a bluish coloration of the cervix and vaginal mucosa (Chadwick's sign). The uterus typically is pear shaped and mobile, with a smooth surface. It will undergo cell hypertrophy and hyperplasia so that it enlarges throughout the pregnancy to accommodate the growing fetus. During the pelvic examination, a Papanicolaou (Pap) smear may be obtained. Additional cultures, such as for gonorrhea and chlamydia screening, also may be obtained. Ensure that all specimens obtained are labeled correctly and sent to the laboratory for evaluation. A rectal examination is done last to assess for lesions, masses, prolapse, or hemorrhoids. Once the examination of the internal genitalia is completed and the speculum is removed, a bimanual examination is performed to estimate the size of the uterus to confirm dates and to palpate the ovaries. The ovaries should be small and nontender, without masses. At the conclusion of the bimanual examination, the health care provider reinserts the index finger into the vagina and the middle finger into the rectum to assess the strength and regularity of the posterior vaginal wall. PELVIC SIZE, SHAPE, AND MEASUREMENTS The size and shape of the women's pelvis can affect her ability to deliver vaginally. Pelvic shape is typically classified as one of the four types: gynecoid, android, anthropoid, and platypelloid. Refer to Chapter 13 for an in-depth discussion of pelvic size and shape. Taking internal pelvic measurements determines the actual diameters of the inlet and outlet through which the fetus will pass. This is extremely important if the woman has never given birth vaginally. Taking pelvic measurements is unnecessary for the woman who has given birth vaginally before (unless she has experienced some type of trauma to the area) because vaginal delivery demonstrates that the pelvis is adequate for the passage of the fetus. Three measurements are assessed: diagonal conjugate, true conjugate, and ischial tuberosity (Fig. 12.4). The diagonal conjugate is the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis (Bope & Kellerman, 2015). This measurement, usually 12.5 cm or greater, represents the anteroposterior diameter of the pelvic inlet through which the fetal head passes first. The diagonal conjugate is the most useful measurement for estimating pelvic size because a misfit with the fetal head occurs if it is too small. The true conjugate, also called the obstetric conjugate, is the measurement from the anterior surface of the sacral prominence to the posterior surface of the inferior margin of the symphysis pubis. This diameter cannot be measured directly; rather, it is estimated by subtracting 1 to 2 cm from the diagonal conjugate measurement. The average true conjugate diameter is at least 11.5 cm (Cunningham et al., 2014). This measurement is important because it is the smallest front-to-back diameter through which the fetal head must pass when moving through the pelvic inlet. FIGURE 12.4 Pelvic measurements. A. Diagonal conjugate (solid line) and true conjugate (dotted line). B. Ischial tuberosity diameter. The ischial tuberosity diameter is the transverse diameter of the pelvic outlet. This measurement is made outside the pelvis at the lowest aspect of the ischial tuberosities. A diameter of 10.5 cm or more is considered adequate for passage of the fetal head (Tharpe, Farley, & Jordan, 2016). (Ricci 375-376) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Follow up visits

Up to 28 weeks gestation, follow-up visits involve assessment of the client's blood pressure and weight. The urine is tested for protein and glucose. Fundal height and fetal heart rate are assessed at every office visit. The best procedure for screening and diagnosing gestational diabetes remains controversial. All strategies involve an oral glucose test, but there remains disagreement about how many grams of glucose (50, 75, or 100) the woman ingests and how long afterwards, her blood sample is drawn. A recent Cochrane Review concluded that there was insufficient evidence to permit assessment of which is the best method to use to identify women who have gestational diabetes (Farrar et al., 2015). Screening for gestational diabetes is best done between 24 and 28 weeks gestation, unless screening is warranted in the first trimester for high-risk reasons (obesity, >25 years old, family history of diabetes, history of gestational diabetes, or woman is of a certain ethnic group: Hispanic, Native Americans, Asian, or African American) (U.S. Preventive Services Task Force [USPSTF], 2015). Between weeks 24 and 28, a blood glucose level is obtained using an oral 50-g glucose load followed by a 1-hour plasma glucose determination. If the result is more than 130 (ADA) to140 (ACOG) mg/dL, further testing, such as a 3-hour 100-g glucose tolerance test, is warranted to determine whether gestational diabetes is present (Farrar et al., 2015). Because insulin resistance increases as pregnancy advances, testing at this gestational point yields a higher rate of abnormal test results. p. 377 p. 378 During this time, review the common discomforts of pregnancy, evaluate any client complaints, and answer questions. Reinforce the importance of good nutrition and use of prenatal vitamins, along with daily exercise. Between 29 and 36 weeks gestation, all the assessments of previous visits are completed, along with assessment for edema. Special attention is focused on the presence and location of edema during the last trimester. Pregnant women commonly experience dependent edema of the lower extremities from constriction of blood vessels secondary to the heavy gravid uterus. Periorbital edema around the eyes, edema of the hands, and pretibial edema (edema on the front, or shin part of the leg) are abnormal and could be signs of gestational hypertension. Inspecting and palpating both extremities, listening for complaints of tight rings on fingers, and observing for swelling around the eyes are important assessments. Abnormal findings in any of these areas need to be reported. If the mother is Rh negative, her antibody titer is evaluated. RhoGAM is given if indicated. RhoGAM is used to prevent development of antibodies to Rh+ red cells whenever fetal cells are known or suspected of entering the maternal circulation such as after a spontaneous abortion or amniocentesis. It is also recommended for prophylaxis at 28 weeks gestation and following birth if the infant is Rh+ (King et al., 2015). The client also is evaluated for risk of preterm labor. At each visit, ask if she is experiencing any common signs or symptoms of preterm labor (e.g., uterine contractions, dull backache, feeling of pressure in the pelvic area or thighs, increased vaginal discharge, menstrual-like cramps, vaginal bleeding). If the woman has had a previous preterm birth, she is at risk for another and close monitoring is warranted. An initial preterm labor evaluation if the woman reports signs and symptoms of preterm labor includes: review of prenatal record for risk factors, evaluation of reported symptoms (uterine contractions, vital signs, fetal heart rate, pelvic exam for cervical dilation and effacement assessment, and status of fetal membranes), and a urine culture to diagnose asymptomatic bacteriuria (Jordan et al., 2014). If positive for preterm labor, the woman may be requested to rest and medications to stop contractions may be in order. Counsel the woman about choosing a health care provider for the newborn, if she has not selected one yet. Along with completion of a breast assessment, the nurse should discuss and educate the client about the choice of breast-feeding versus bottle-feeding. The American Academy of Pediatrics (AAP) does encourage all mothers to breast-feed their offspring, but the decision to do so is the woman's ultimately. The nurse can refer the client to Nursing Mothers and La Leche League web sites for further information to assist her in making that decision. Reinforce the importance of daily fetal movement monitoring as an indicator of fetal well-being. Re-evaluate hemoglobin and hematocrit levels to assess for anemia. Between 37 and 40 weeks gestation, the same assessments are done as for the previous weeks. In addition, screening for group B streptococcus, gonorrhea, and chlamydia is done. Fetal presentation and position (via Leopold's maneuvers) are assessed. Review the signs and symptoms of labor and forward a copy of the prenatal record to the hospital labor department for future reference. Review the client's desire for family planning after birth as well as her decision to breast-feed or bottle-feed. Remind the client that an infant car seat is required by law and must be used to drive the newborn home from the hospital or birthing center. (Ricci 377-378) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Exercise

A physically inactive lifestyle is associated with an increase in chronic diseases such as cardiovascular disease, type 2 diabetes, osteoporosis, and cancer. The proportion of pregnant women who are overweight or obese is increasing globally, thus exercise is essential to reduce these risks and promote a healthy pregnancy. Exercise is well tolerated by a healthy woman during pregnancy. It promotes a feeling of well-being; improves circulation; helps reduce constipation, bloating, and swelling; may help prevent or treat gestational diabetes; promotes muscle tone, strength, and endurance; may improve the woman's ability to cope with labor; increases energy level; improves posture; helps sleep and promotes relaxation and rest; and relieves the lower back discomfort that often arises as the pregnancy progresses (Barakat, Lucia, & Ruiz, 2015). However, the duration and difficulty of exercise should be modified throughout pregnancy because of a decrease in performance efficiency with gestational age. Some women continue to push themselves to maintain their prior level of exercise, but most find that as their shape changes and their abdominal area enlarges, they must modify their exercise routines. Modification also helps to reduce the risk of injury caused by laxity of the joints and connective tissue due to the hormonal effects (Petrov, Glantz, & Fagevik Olsen, 2015). Exercise during pregnancy is contraindicated in women with preterm labor, poor weight gain, anemia, facial and hand edema, pain, hypertension, threatened abortion, dizziness, shortness of breath, multiple gestation, decreased fetal activity, cardiac disease, and palpitations (Rigby, 2015). Federal physical activity guidelines recommend at least 150 minutes of moderate-intensity exercise per week during pregnancy (Fig. 12.10) (Dietz, 2015). It is believed that pregnancy is a unique time for behavior modification and that healthy behaviors maintained or adopted during pregnancy may improve the woman's health for the rest of her life. The excess weight gained in pregnancy, which some women never lose, is a major public health problem (Truong et al., 2015). Exercise helps the woman avoid gaining excess weight during pregnancy. Exercise during pregnancy helps return a woman's body to good health after the baby is born. The long-term benefits of exercise that begin in early pregnancy include improved posture, weight control, and improved muscle tone. Exercise also aids in the prevention of osteoporosis after menopause, reduces the risk of hypertension and diabetes, and assists in keeping the birth weight of the fetus within the normal range (Barakat et al., 2015). Teaching Guidelines 12.2 highlights recommendations for exercise during pregnancy. (Ricci 397) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Laboratory tests

A series of tests is generally ordered during the initial visit so that baseline data can be obtained, allowing for early detection and prompt intervention if any problems occur. Tests that are generally conducted for all pregnant women include urinalysis and blood studies. The urine is analyzed for albumin, glucose, ketones, and bacteria casts. Blood studies usually include a complete blood count (CBC) (hemoglobin, hematocrit, red and white blood cell counts, and platelets), blood typing and Rh factor, glucose screening for high-risk women, a rubella titer, hepatitis B surface antibody antigen, HIV, venereal disease research laboratory (VDRL) or rapid plasma reagin (RPR) tests, and cervical smears to detect STIs (Common Laboratory and Diagnostic Tests 12.1). In addition, most offices and clinics have ultrasound equipment available to validate an intrauterine pregnancy and assess early fetal growth. The need for additional laboratory studies is determined by a woman's history, physical examination findings, current health status, and risk factors identified in the initial interview. Additional tests can be offered (e.g., screening for genetic diseases, blood lead screening, rubeola, and so on), but ultimately the woman and her partner make the decision about undergoing them. Educate the client and her partner about the tests, including the rationale. In addition, support the client and her partner in their decision-making process, regardless of whether you agree with the couple's decision. The couple's decisions about their health care are based on the ethical principle of autonomy, which allows an individual the right to make decisions about his or her own body. (Ricci 376) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Chest assessment

Auscultate heart sounds, noting any abnormalities. A soft systolic murmur caused by the increase in blood volume may be noted. Anticipate an increase in heart rate by 10 to 15 beats per minute (bpm) (starting between 14 and 20 weeks of pregnancy) secondary to increases in cardiac output and blood volume. The body adapts to the increase in blood volume with peripheral dilation to maintain blood pressure. Progesterone causes peripheral dilation. Auscultate the chest for breath sounds, which should be clear. Also note symmetry of chest movement and thoracic breathing patterns. Estrogen promotes relaxation of the ligaments and joints of the ribs, with a resulting increase in the anteroposterior chest diameter. Expect a slight increase in respiratory rate to accommodate the increase in tidal volume and oxygen consumption. Inspect and palpate the breasts and nipples for symmetry and color. Increases in estrogen and progesterone and blood supply make the breasts feel full and more nodular, with increased sensitivity to touch. Blood vessels become more visible and there is an increase in breast size. Striae gravidarum (stretch marks) may be visible in women with large breasts. Darker pigmentation of the nipple and areola is present, along with enlargement of Montgomery's glands. Colostrum (yellowish secretion that precedes mature breast milk) is excreted typically in the third trimester. (Ricci 374) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Doppler flow studies

Comprehensive assessment of fetal well-being involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques forms the foundation of prenatal diagnosis of structural anomalies, rhythm abnormalities, and altered fetal circulation (Pruetz, Votava-Smith, & Miller, 2015). Doppler flow studies can be used to measure the velocity of blood flow via ultrasound. Doppler flow studies can detect fetal compromise in high-risk pregnancies. The test is noninvasive and has no contraindications. The color images produced help to identify abnormalities in diastolic flow within the umbilical vessels. The velocity of the fetal red blood cells can be determined by measuring the change in the frequency of the sound wave reflected off the cells. Thus, Doppler flow studies can detect the movement of red blood cells in vessels (Everett & Peebles, 2015). In pregnancies complicated by hypertension or FGRs, diastolic blood flow may be absent or even reversed (Alfirevic, Stampalija, & Medley, 2015). Doppler flow studies also can be used to evaluate the blood flow through other fetal blood vessels, such as the aorta and those in the brain. Research continues to determine the indications for Doppler flow studies to improve pregnancy outcomes. Nursing management of the woman undergoing Doppler flow studies is similar to that described for an ultrasound. (Ricci 381) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Follow up visits

Continuous prenatal care is important for a successful pregnancy outcome. The recommended follow-up visit schedule for a healthy pregnant woman is as follows: Every 4 weeks up to 28 weeks (7 months) Every 2 weeks from 29 to 36 weeks Every week from 37 weeks to birth At each subsequent prenatal visit, the following assessments are completed: Weight and blood pressure, which are compared with baseline values Urine testing for protein, glucose, ketones, and nitrites Fundal height measurement to assess fetal growth Assessment for quickening/fetal movement to determine fetal well-being Assessment of fetal heart rate (should be 110 to 160 bpm) (Ricci 376) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Assessment of Fetal Well-Being

During the antepartum period, several tests are performed routinely to monitor fetal well-being and to detect possible problems. When a high-risk pregnancy is identified, additional antepartum testing can be initiated to promote positive maternal, fetal, and neonatal outcomes. High-risk pregnancies include those that are complicated by maternal or fetal conditions (coincidental with or unique to pregnancy) that jeopardize the health status of the mother and put the fetus at risk for uteroplacental insufficiency, hypoxia, and death (CDC, 2015d). However, additional antepartum fetal testing should take place only when the results obtained will guide future care, whether it is reassurance, more frequent testing, admission to the hospital, or the need for immediate delivery (Brown, 2015). (Ricci 380) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Comprehensive health history

During the initial visit, a comprehensive health history is obtained, including age, menstrual history, prior obstetric history, past medical and surgical history, psychological screening, family history, genetic screening, dietary habits, lifestyle and health practices, medication or drug use, and history of exposure to STIs (Moses, 2015a). Often, use of a prenatal history form (Fig. 12.2) is the best way to document the data collected (see Evidence-Based Practice 12.2). The initial health history typically includes questions about three major areas: the reason for seeking care; the client's past medical, surgical, and personal history, including that of the family and her partner; and the client's reproductive history. During the history-taking process, the nurse and client establish the foundation of a trusting relationship and jointly develop a plan of care for the pregnancy. They tailor this plan to the client's lifestyle as much as possible and focus primarily on education for overall wellness during the pregnancy. The ultimate goal for the first prenatal visit is to collect baseline data about the woman and her partner and to detect any risk factors that need to be addressed to facilitate a healthy pregnancy (King et al., 2015). See Healthy People 2020 12.1. (Ricci 368) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Fundal height measurement

Fundal height is the distance (in centimeters) measured with a tape measure from the top of the pubic bone to the top of the uterus (fundus) with the client lying on her back with her knees slightly flexed (Fig. 12.5). Measurement in this way is termed the McDonald's method. Fundal height typically increases as the pregnancy progresses; it reflects fetal growth and provides a gross estimate of the duration of the pregnancy. Between 12 and 14 weeks gestation, the fundus can be palpated above the symphysis pubis. The fundus reaches the level of the umbilicus at approximately 20 weeks and measures 20 cm. Fundal measurement should approximately equal the number of weeks of gestation until week 36. For example, a fundal height of 24 cm suggests a fetus at 24 weeks gestation. After 36 weeks, the fundal height then drops due to lightening and may no longer correspond with the week of gestation. It is expected that the fundal height will increase progressively throughout the pregnancy, reflecting fetal growth. However, if the growth curve flattens or stays stable, it may indicate the presence of FGR. If the fundal height measurement is greater than 4 cm from the estimated gestational age, further evaluation is warranted if a multifetal gestation has not been diagnosed or hydramnios has not been ruled out (Weber & Kelley, 2014). (Ricci 378-379) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Sleep and rest

Getting enough sleep helps a person feel better and promotes optimal performance levels during the day. The body releases its greatest concentration of growth hormone during sleep, helping the body to repair damaged tissue and grow. Also, with the increased metabolic demands during pregnancy, fatigue is a constant challenge to many pregnant women, especially during the first and third trimesters. The following tips can help promote adequate sleep: Stay on a regular schedule by going to bed and waking up at the same times. Eat regular meals at regular times to keep external body cues consistent. Take time to unwind and relax before bedtime. Establish a bedtime routine or pattern and follow it. Create a proper sleep environment by reducing the light and lowering the room temperature. Go to bed when you feel tired; if sleep does not occur, read a book until you are sleepy. Reduce caffeine intake later in the day. Limit fluid intake after dinner to minimize trips to the bathroom. Exercise daily to improve circulation and well-being. Use a modified Sims position to improve circulation in the lower extremities. Avoid lying on your back after the fourth month, which may compromise circulation to the uterus. Avoid sharply bending your knees, which promotes venous stasis below the knees. Keep anxieties and worries out of the bedroom. Set aside a specific area in the home or time of day for them. (Ricci 398-399) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Extremetis assessment

Inspect and palpate both legs for dependent edema, pulses, and varicose veins. If edema is present in early pregnancy, further evaluation may be needed to rule out gestational hypertension. During the third trimester, dependent edema is a normal finding. Ask the woman if she has any pain in her calf that increases when she ambulates. This might indicate a deep vein thrombosis (DVT). High levels of estrogen during pregnancy place women at higher risk for DVT. (Ricci 375) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Clothing

Many contemporary clothes are loose fitting and layered, so the woman may not need to buy an entirely new wardrobe to accommodate her pregnancy. Some pregnant women may continue to wear tight clothes. Point out that loose clothing will be more comfortable for the client and her expanding waistline. Advise pregnant women to avoid wearing constricting clothes and girdles that compress the growing abdomen. Urge the woman to avoid knee-high hose, which might impede lower-extremity circulation and increase the risk of developing DVT. Low-heeled shoes will minimize pelvic tilt and possible backache. Wearing layered clothing that can be removed as the temperatures fluctuate may be more comfortable, especially toward term, when the woman may feel overheated. (Ricci 397) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Employment

Nearly three-quarters of pregnant women in the United States will continue to work outside the home until the last month of pregnancy (Jordan et al., 2014). For the most part, women can continue working until giving birth if they have no complications during their pregnancy and the workplace does not present any special hazards (Zolotor & Carlough, 2014). Hazardous occupations include health care workers, daycare providers, laboratory technicians, chemists, painters, hairstylists, veterinary workers, and carpenters (Guidotti, 2014). Jobs requiring strenuous work such as heavy lifting, climbing, carrying heavy objects, and standing for prolonged periods place a pregnant woman at risk if modifications are not instituted. Assess for environmental and occupational factors that place a pregnant women and her fetus at risk for injury. Interview the woman about her employment environment. Ask about possible exposure to teratogens (substances with the potential to alter the fetus permanently in form or function) and the physical demands of employment: Is she exposed to temperature extremes? Does she need to stand for prolonged periods in a fixed position? A description of the work environment is important in providing anticipatory guidance to the woman. Stress the importance of taking rest periods throughout the day, because constant physically intensive workloads increase the likelihood of low birth weight and preterm labor and birth (Cunningham et al., 2014). Because of the numerous physiologic and psychosocial changes that women experience during their pregnancies, the employer may need to make special accommodations to reduce the pregnant woman's risk of hazardous exposures and heavy workloads. The employer may need to provide adequate coverage so that the woman can take rest breaks; remove the woman from any areas where she might be exposed to toxic substances; and avoid work assignments that require heavy lifting, hard physical labor, continuous standing, or constant moving. Some recommendations for working while pregnant are given in Teaching Guidelines 12.3. (Ricci 400) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

nuchal translucency

Nuchal translucency screening (ultrasound) is also done in the first trimester between 11 and 14 weeks. This allows for early detection and diagnosis of some fetal chromosomal and structural abnormalities. Over the years, it has become clear that increased nuchal translucency is a marker for chromosomal abnormalities, and is also associated with a wide spectrum of structural anomalies, genetic syndromes, and high risk of abortion and fetal death (Rayburn, Jolley, & Simpson, 2015). Ultrasound is used to identify an increase in nuchal translucency, which is due to the subcutaneous accumulation of fluid behind the fetal neck. Increased nuchal translucency is associated with chromosomal abnormalities such as trisomies 21, 18, and 13. Infants with trisomies tend to have more collagen and elastic connective tissue, allowing for accumulation. In addition, diaphragmatic hernias, cardiac defects, and fetal skeletal and neurologic abnormalities have been associated with increased nuchal translucency measurements (Evans, Andriole, & Evans, 2015). See Chapter 10 for more information. (Ricci 383) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Fetal movement and heart rate

Perception of fetal movement typically begins in the second trimester, and occurs earlier in multiparous women versus nulliparous women. The mother's first perception of fetal movement, termed "quickening," is commonly described as a gentle fluttering. This perceived fetal movement is most often related to trunk and limb motion and rollovers, or flips (Moses, 2015b). Maternal perception of fetal movement is an important screening method for fetal well-being, because decreased fetal movement is associated with a range of pregnancy pathologies and poor pregnancy outcomes. Decreased fetal movement may indicate asphyxia and FGR. If compromised, the fetus decreases its oxygen requirements by decreasing activity. Reduced fetal movement is thought to represent fetal compensation in a chronic hypoxic environment due to inadequacies in the placental supply of oxygen and nutrients (Fretts, 2014). A decrease in fetal movement may also be related to other factors as well, such as maternal use of central nervous system depressants, fetal sleep cycles, hydrocephalus, bilateral renal agenesis, stillbirth, placental dysfunction, and bilateral hip dislocation (Heazell, 2015). Fetal movement counting is a method used by the mother to quantify her fetus's movement. However, the optimal number of movements and the ideal duration of counting them remain controversial. Many variations for determining fetal movement, also called fetal movement counts, have been developed, but the one most common method is described as follows. Determining fetal movement is a noninvasive method of screening and can be easily taught to all pregnant women. Any technique used requires client participation and cooperation. Instruct the client about how to count fetal movements, the reasons for doing so, and the significance of decreased fetal movements. Urge the client to perform the counts in a relaxed environment and a comfortable position, such as semi-Fowler's or side-lying. Provide the client with detailed information concerning fetal movement counts and stress the need for consistency in monitoring (at approximately the same time each day) and the importance of informing the health care provider promptly of any reduced movements. Providing clients with "fetal kick count" charts to record movement helps promote adherence to your instructions. No values for fetal movement have been established that indicate fetal well-being, so the woman needs to be aware of a decrease in the number of movements when last assessed. The most common method used is "Count to 10," whereby a woman focuses her attention on her fetus's movement and records how long it takes to document 10 movements. If it takes longer than 2 hours, the woman should contact her health care provider for further evaluation. Fetal kick counting in current prenatal care appears to be underutilized and nurses need to educate women about this assessment in their pregnancy care. Fetal Heart Rate Measurement Fetal heart rate measurement is integral to fetal surveillance throughout the pregnancy. Auscultating the fetal heart rate with a handheld Doppler at each prenatal visit helps confirm that the intrauterine environment is still supportive to the growing fetus. The purpose of assessing fetal heart rate is to determine the rate and rhythm. The normal fetal heart rate range is 110 to 160 bpm. Nursing Procedure 12.1 lists the steps in measuring fetal heart rate. (Ricci 379) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Abdominal assessment

The appearance of the abdomen depends on the number of weeks of gestation. The abdomen enlarges progressively as the fetus grows. Inspect the abdomen for striae, scars, shape, and size. Inspection may reveal striae gravidarum (stretch marks) and linea nigra, a thin brownish black pigmented line running from the umbilicus to the symphysis pubis, depending on the duration of the pregnancy. Palpate the abdomen, which should be rounded and nontender. A decrease in muscle tone may be noted due to the influence of progesterone. Typically, the height of the fundus is measured when the uterus arises out of the pelvis to evaluate fetal growth. At 12 weeks gestation the fundus can be palpated at the symphysis pubis. At 16 weeks gestation the fundus is midway between the symphysis and the umbilicus. At 20 weeks the fundus can be palpated at the umbilicus and measures approximately 20 cm from the symphysis pubis. By 36 weeks the fundus is just below the xiphoid process and measures approximately 36 cm. The uterus maintains a globular/ovoid shape throughout pregnancy (Bope & Kellerman, 2015). (Ricci 375) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016.

Final preparation

The nurse has played a supportive/education role for the couple throughout the pregnancy and now needs to assist in preparing them for their "big event" by making sure they have made informed decisions and completed the following checklist: Attended childbirth preparation classes and practiced breathing techniques Selected a birth setting and made arrangements there Know what to expect during labor and birth Toured the birthing facility Packed a suitcase to take to the birthing facility when labor starts Made arrangements to have siblings and/or pets taken care of during labor Been instructed on signs and symptoms of labor and what to do Know what to do if membranes rupture prior to going into labor Know how to reach their health care provider when labor starts Communicated their needs and desires concerning pain management Discussed the possibility of a cesarean birth if complications occur Discussed possible names for the newborn Selected a feeding method (breast or bottle) with which they feel comfortable Made a decision regarding circumcision if they have a boy Purchased an infant safety car seat in which to bring their newborn home Decided on a pediatrician Have items needed to prepare for the newborn's homecoming: Infant clothes in several sizes Nursing bras Infant crib with spaces between the slats that are 2 inches or less apart Diapers (cloth or disposable) Feeding supplies (bottles and nipples if bottle-feeding) Infant thermometer Selected a family planning method to use after the birth At each prenatal visit the nurse has had the opportunity to discuss and reinforce the importance of being prepared for the birth of the child with the parents. It is now up to the parents to use the nurse's guidance and put it into action to be ready for the upcoming birth. A recent national survey entitled Listening to Mothers III: Pregnancy and Birth revealed concerns about overuse of maternity care practices and women's readiness to make informed decisions. Key findings point to the need for quality improvement, consumer engagement, and shared decision making (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2014). These findings present a challenge for all nurses caring for maternity clients to thoroughly explain all procedures, along with their rationales, and truly listen to what the woman desires to make her childbirth experience outcome a positive one for her. All nurses have the responsibility to impart their knowledge to all women and their families—and that starts with teaching themselves first. The evidence is clear that women have better outcomes when nurses intervene only when needed in the childbirth process. Nurses need to personalize their care to every woman based on her needs, her desires, and her state of health. Nurses must focus on teaching women and their families to understand the value of birth and its long-lasting effects on the family. In addition, nurses must provide birth settings that are safe, whether in the hospital, birth center, or at home. This includes, but is not limited to, providing continuous support in labor, allowing women the freedom to move and assume positions of choice, offering nourishment of the woman's body and spirit, using nonpharmacologic pain-relief modalities whenever possible, and ensuring seamless, collaborative teamwork. Continuous labor support is a nonpharmacologic, evidence-based strategy associated with reduced cesarean rates (Baum, Crawford, & Humphrey-Shelton, 2015). (Ricci 410-411) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

True

The period of greatest environmental sensitivity and consequent risk for the developing embryo is between days 17 and 56 after conception (Ricci 364) most of the time a woman's first prenatal visit is a month after the last missed period and they may be too late to prevent environmental damage

marker screening tests

Using maternal serum is an effective, noninvasive method for identifying fetal risk for aneuploidy (trisomies 13, 18, and 21) and neural tube defects. Prenatal screening for Down syndrome in the early second trimester with multiple maternal serum markers has been available for more than 15 years. Abnormalities in maternal serum marker levels and fetal measurements obtained during the first trimester screening can be markers for not only certain chromosomal disorders and anomalies in the fetus, but also for specific pregnancy complications. Pregnancy-associated plasma protein A (PAPP-A) is a key regulator of insulin-like growth factor essential for normal fetal development. In maternal blood, this protein increases with gestational age. It is routinely used for Down syndrome screening in the first trimester. A low maternal serum PAPP-A, at 11 to 13 weeks of gestation, is associated with stillbirth, infant death, preterm birth, preeclampsia, and chromosomal abnormalities (Kalousová, Muravská, & Zima, 2014; Patil, Panchanadikar, & Wagh, 2014). Multiple blood screening tests may be used to determine the risk of open neural tube defects and Down syndrome: the triple-marker screen (AFP, hCG, and unconjugated estriol) or the quad screen, which includes the triple screening tests with the addition of a fourth marker, inhibin A (glycoprotein secreted by the placenta). The quad screen is used to enhance the accuracy of screening for Down syndrome in women younger than 35 years of age. Low inhibin A levels indicate the possibility of Down syndrome (ACOG, 2015b). These biomarkers are merely screening tests and identify women who need further definitive procedures (i.e., ultrasound, amniocentesis, and genetic counseling) to make a diagnosis of neural tube defects (anencephaly, spina bifida, and encephalocele) or Down syndrome in the fetus. Most screening tests are performed between 15 and 22 weeks of gestation (16 to 18 weeks is ideal), except for the cffDNA test which can be performed around 9 to 10 weeks gestation (Dempsey & Overton, 2015). With these multiple screening tests, low maternal serum AFP (MSAFP), unconjugated estriol levels, and a high hCG level suggest the possibility of Down syndrome. Elevated levels of MSAFP are associated with open neural tube defects, ventral wall defects, some renal abnormalities, multiple gestation, certain skin disorders, fetal demise, and placental abnormality. The multiple marker combination with the highest screening performance currently available is AFP, unconjugated estriol (uE3), hCG, and inhibin A, together with maternal age (the so-called quad marker test). With this combination, a detection rate of 80% at a 5% false-positive rate is achieved (Hixson et al., 2015). A number of factors influence the interpretation of an MSAFP value. The most important is the accuracy of the gestational age determination. A variation of 2 weeks can be misleading and lead to a wrong interpretation. Maternal weight (>250 pounds), ethnicity, maternal smoking habits, fetal gender, gravidity, para status, and women with insulin-dependent diabetes also may alter the levels of MSAFP and need to be taken into consideration when interpreting the results (Latendresse & Deneris, 2015). Recent research studies indicate prenatal testing with the use of cell free DNA (cfDNA) has significantly lower false positives and high positive predictive values for detection of trisomies than standard testing (Greeley, Kessler, & Vohra, 2015). (Ricci 382-383) Nursing Management Accurate test interpretation and risk determination are dependent on accurate pregnancy dating and reporting of relevant maternal characteristics. This is why it is so important for nurses, if an abnormal test result is reported, for them to confirm pregnancy dating and report any significant maternal factors relevant to test accuracy. In addition, nurses have a big role in providing education about the tests to the couples. Prenatal screening has become standard in prenatal care. However, for many couples it remains confusing, emotionally charged, and filled with uncertain risks. Offer a thorough explanation of the test, reinforcing the information given by the health care professional. Provide couples with a description of the risks and benefits of performing these screens, emphasizing that these tests are for screening purposes only. Remind the couple that a definitive diagnosis is not made without further tests such as an amniocentesis. Answer any questions about these prenatal screening tests and respect the couple's decision if they choose not to have them done. Many couples may choose not to know because they would not consider having an abortion regardless of the test results. (Ricci 383) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Immunizations and medications

Vaccines are among the greatest public health achievements of the twenty-first century, credited with significant reduction of morbidity and mortality from many diseases caused by bacteria and viruses (Senie, 2014). Ideally, clients should receive all childhood immunizations before conception to protect the fetus from any risk of congenital anomalies. If the client comes for a preconception visit, discuss immunizations such as measles, mumps, and rubella (MMR), hepatitis B, and diphtheria/tetanus (every 10 years); administer them at this time if needed. The risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. Routine immunizations are not usually indicated during pregnancy. However, no evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. A number of other vaccines have not been adequately studied, and thus theoretical risks of vaccination must be weighed against the risks of the disease to mother and fetus (CDC, 2015f). p. 401 p. 402 Take Note! Advise pregnant women to avoid live virus vaccines (MMR and varicella) and to avoid becoming pregnant within 1 month of having received one of these vaccines because of the theoretical risk of transmission to the fetus (CDC, 2015f). CDC guidelines for vaccine administration are highlighted in Box 12.6. Little is known about the effects of taking most medications during pregnancy. Less than 10% of medications approved by the FDA since 1980 have enough information to determine their risk for birth defects (CDC, 2015g). Based on this lack of evidence, it is best for pregnant women not to take any medications during their pregnancy. At the very least, encourage them to discuss with the health care provider their current medications and any herbal remedies they take so that they can learn about any potential risks should they continue to take them during pregnancy. Generally, if the woman is taking medicine for seizures, high blood pressure, asthma, or depression, the benefits of continuing the medicine during pregnancy outweigh the risks to the fetus. The safety profile of some medications may change according to the gestational age of the fetus. Embryogenesis is completed by the end of the first trimester, when all fetal organs are complete. Thus, to cause a malformation, fetal drug exposure must occur in the first 12 weeks of gestation (Gadot & Koren, 2015). BOX 12.6 CDC GUIDELINES FOR VACCINE ADMINISTRATION DURING PREGNANCY Vaccines That Should Be Considered if Otherwise Indicated Hepatitis B Influenza (inactivated) injection Tetanus/diphtheria (Tdap) Meningococcal Rabies Vaccines Contraindicated During Pregnancy Influenza (live, attenuated vaccine) nasal spray Measles Mumps Rubella Varicella BCG (tuberculosis) Meningococcal Typhoid Adapted from Centers for Disease Control and Prevention. (2015f). Vaccines for pregnant women. Retrieved from http://www.cdc.gov/vaccines/adults/rec-vac/pregnant.html; March of Dimes. (2015h). Vaccinations during pregnancy. Retrieved from http://www.marchofdimes.com/pregnancy/vaccinations-during-pregnancy.aspx The FDA has developed a system of ranking drugs that appears on drug labels and package inserts. These risk categories are summarized in Box 12.7. Always advise women to check with the health care provider for guidance. A common concern of many pregnant women involves the use of over-the-counter medications and herbal agents. Many women consider these products benign simply because they are available without a prescription (King et al., 2015). Although herbal medications are commonly thought of as "natural" alternatives to other medicines, they can be just as potent as some prescription medications. A major concern about herbal medicine is the lack of consistent potency in the active ingredients in any given batch of product, making it difficult to know the exact strength by reading the label. Also, many herbs contain chemicals that cross the placenta and may cause harm to the fetus. Nurses are often asked about the safety of over-the-counter medicines and herbal agents. Unfortunately, many drugs have not been evaluated in controlled studies, and it is difficult to make general recommendations for these products. Therefore, encourage pregnant women to check with their health care provider before taking anything. Questions about the use of over-the-counter and herbal products are part of the initial prenatal interview. (Ricci 401-402) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.