Chapter 11

Assessing Fetal and Maternal Health

Health Promotion during pregnancy

Purposes of prenatal care:
Establish a baseline of present health
Determine gestational age of the fetus
Monitor fetal devt and maternal wellbeing
Identify women @ risk for complications
Minimize the risk of possible complications by anticipating and preventing probs before they
occur
Provide time for education about pregnancy, lactation and newborn care
Prenatal Management
1st prenatal visit
As soon as mother missed a menstrual period when pregnancy is suspected
Major causes of death for pregnancy:
Ectopic pregnancy, HPN, hemorrhage, embolism, anesthesia-relate complications
(intrapartum cardiac arrest)
Schedule of prenatal visits
Once a month: up to 1st 32 weeks
2 x a month (q 2 weeks): 32 – 36 weeks
4 x a month (q week): 36 – 40 weeks
Presence of danger signals of pregnancy – mother shd be instructed to report promptly for
evaluation
Conduct of initial visit
Baseline data collection
Basis for comparison
To screen for high-risk factors
OB history
Menstrual hx – menarche (onset, regularity, duration, frequency, character)
LMP, sexual hx, methods of contraception
PMP – menstrual period before the LMP
Conduct of Initial visit
Medical and surgical hx
Past illnesses and surgical procedures, current drugs used
Family hx
To detect illnesses or conditions that are transmittable
Current problems
ADL, discomforts, danger signs
Initial and subsequent visits
Vital signs
Temperature
 rate: plus 10 – 15 bpm
RR: tend to be rapid and deep (16/min)
BP: tends to be hypotensive w/ supine position
Elevated BP = PIH
Do roll-over test in 1st trimester – for early detection of developing PIH by 20 – 24
weeks
Roll-Over Test
Procedure:
Place mother on LLR
Check BP until stable, may take 10 – 15 mins
Roll to supine
Check BP right away
Wait for 5 mins
Check BP again. Compare w/ 2nd diastolic reading
Interpretation:
Positive:  in diastolic pressure greater than 20 mmHG; woman @ risk
Negative:  in diastolic pressure less than 20 mmHG

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 Initial and subsequent visits
Weight
Checked in q visit
1st trimester: 1 lb/ mo (3 – 4 lb total)
2nd trimester: 0.9 – 1 lb/week to about 10 – 12 lb
3rd trimester: 0.5 – 1 lb/week 8 – 11 lb*
Weight is a measue of health of a mother
Urine testing for albumin and sugar
Sugar – ideally not more than 1+
Albumin – negative; nephritis
Fetal growth and devt assessment
Fundal height
FHT/FHR
Abdominal palpation
Quickening – 1st plus subsequent movements
Initial and subsequent visits
OB history
4-Point system: past pregnancies and perinatal outcomes (FPAL)
5-Point System: GFPAL
Estimates in Pregnancy
EDC/EDD
Naegele’s Rule
Mittendorf’s Rule
Date of Quickening
Fundic Height
AOG
McDonald’s Rule (2nd and 3rd trimester)
Bartholomew’s Rule of Fours
Estimated fetal weight (EFW)
Johnson’s Rule
Estimated fetal height in cm (EFL)
Haase’s Rule
Complete physical Examination
Includes internal gynecologic and bimanual examinations
Internal examination (IE)
Detects early signs of pregnancy
Chadwick’s, Goodell’s, and Hegar’s signs
Preparations for IE
Explanation
Void before
Proper positioning:
Draping
Instructions:
DON’Ts:
Complete physical Examination
Impt. Concerns of PE:
Breasts: look for changes, adequacy of breasts for breastfeeding, abnormal signs
Abdomen: Fundic height; Leopold’s
Pelvic measurements: done in the 3rd trimester to determine CPD (cephalo-pelvic
disproportions)
Extremities:
Discomforts: leg cramps, varicosities, pedal edema
Danger signs: + Homan’s sign = thrombophlebitis
Laboratory Tests
Blood studies
Complete blood count (CBC)
Hgb: 12 – 16g/dL
Hct: 37 – 47%
Leucocytosis – elevated WBC; normal
– Pregnancy: 5,500 – 11,500/mm3
– Labor: 20,000/mm3
– Postpartum: 25,000/mm3

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 Blood typing and Rh determination
Accdg to institution protocol, Serology for:
Syphylis (VDRL)
Rubella antibody titer
HIV
Alpha-fetoprotein (AFP) screening @ 16 – 18 weeks’ gestation to rule out neural
defects
Urine Test
Tested for sugar
Bacteria – asymptomatic bareriuria w/c can result in abortion in early pregnancy, and
premature labor, late in pregnancy
Laboratory Tests
Pelvic Lab tests
Collection of pelvic cultures
Pap test, culture for gonorrhea and Chlamydia
Bimanual examination
Usually last part of the initial PE
To identify cervical and uterine changes
Detect uterine size
Assess for deviation in expected shape and size
In all the necessary, prepare the client thru the ff steps:
Providing an explanation of the procedure
Physical prep specific to procedure
Provision of support to client and spouse; encouraging verbalization of concerns
Monitoring of client and fetus after procedure
Documentation prn
Assignment:
Rules in the different estimates in Pregnancy
Discomforts in pregnancy and management/relief measures for each discomfort (Tabulated)
Nutritional considerations:
Nutritional profile: pre-pregnant and current nutritional status
What is Pica?
What are some physical findings indicative of poor nutritional status? (@ least 5)
Factors/ conditions requiring special attention (@ least 5)
Nutrient needs:
Calories
Protein
Carbohydrates
Fiber
Fats
Essential minerals: Iron, calcium, sodium, folic acid, vitamins
Daily food needs/servings (Tabulated)
Food:
Number of servings each

Chapter 12
Promoting Fetal and Maternal Health

 Health promotion during pregnancy begins with reviewing self-care

Self-Care Needs
 Because pregnancy is not an illness, few special care measures other than common sense about self-
care are required

 Average woman needs some help separating fact from fiction so that she can enjoy her pregnancy
unhampered by unnecessary restrictions

 Be alert to the common misunderstandings, misconceptions, or inappropriate information of pregnancy

Bathing
 Misconceptions:

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  Tub baths restricted @ one time – water would enter the vagina and cervix and contaminate
the uterine contents
 Hot water touching the abdomen might initiate labor

 Truths:
 Normally vagina is in a closed position – danger of tub bath entering the cervix is minimal
 Water temperature has no documented effect on initiating labor
 During pregnancy, sweating tends
to  because woman excretes Daily tub baths and
waste products for herself and showers are now
the fetus recommended
 Vaginal discharge ed

 As pregnancy advances – woman may have difficulty maintaining her balance when getting in
and out of a bath tub – change to showering or sponge bathing for her own safety
 If membranes rupture or vaginal bleeding present – tub baths contraindicated because of
danger of contamination of uterine contents

 During last month of pregnancy, when uterine cervix may begin to dilate – some health care
providers restrict tub bathing

Breast Care
 Woman shd wear a firm, supportive bra w/ wide straps to spread weight across the shoulders

 May need to buy a larger bra halfway through pregnancy – to accommodate ed breast size

 If plans to breastfeed – choose bras suitable for breast-feeding so she can continue to use them after
baby’s birth

 16th week of pregnancy – colostrum secretion begins in the breast

 Sensation of a fluid discharge can be frightening unless woman is warned that this is a
possibility
 Instruct to wash her breasts w/ clear tap water daily no soap coz it could be drying) – to
remove colostrums and reduce risk of infection
 Dry her nipples well by patting them
 If colostruman secretion is profuse – need to place gauze or breast pads inside her bra,
change frequently – to maintain dryness = constant moisture next to nipple can cause
excoriation, pain, and fissuring

Dental Care
 Gingival tissue hypertrophy during pregnancy
 Unless woman brushes well, pockets of plaque form readily bet. enlarged gumline and teeth
 Encourage to see dentist regularly for routine examination and cleaning – 9 months is a
fairly long time to be w/o preventive dental care
 Woman should question the need for x-rays during pregnancy – if necessary, abdomen should be
shielded w/ a lead apron

 Tooth decay occurs from the action of bacteria on sugar = lowers pH of the mouth, creating an acid
medium  etching or destruction of the enamel of teeth
 Encourage to snack on nutritious foods – fresh fruits and vegetables (apples, carrots) to
avoid sugar coming in contact w/ teeth
 If w/ trouble avoiding sweet snacks – suggest those that dissolve easily (chocolate bar) to
minimize the level of sugar in the mouth

Perineal Hygiene
 Douching is contraindicated – force of irrigating fluid could enter cervix and lead to infection
 Douching alters pH of the vagina = ed risk of bacterial growth

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Dressing
 Avoid:
o Garters May impede
o extremely firm girdles w/ panty legs lower extremity
o knee-high stockings circulation

 Suggest: shoes w/ moderate to low heel – to minimize pelvic tilt and backache

Sexual Activity
 Many need information to refute some myths about sexual relations in pregnancy that still exists, such
as:
o Coitus on expected date of period will initiate labor
o Orgasm will initiate labor; sexual relations w/o orgasm will not cause labor
o Coitus during fertile days of a cycle will cause a 2nd pregnancy or twins
o Coitus might cause rupture of membranes

 Asking a woman @ a prenatal if she has any questions about sexual activity – allows her to voice
concerns; nurse can help dispel myths

 Coitus is contraindicated in the ff. conditions:

o Hx of spontaneous miscarriage
o Ruptured membranes
o Vaginal spotting
o Deeply engaged presenting part
 Advise caution about male oral – female genital contact = accidental air embolism has been reported
from this act during pregnancy

 Couple shd be advised to find a comfortable position for intercourse

 w/ non-monogamous sexual partner – partner needs to use a condom to prevent STIs during
pregnancy

 women may use female condom throughout pregnancy

 Sex in moderation is permitted but not during the last 6 weeks of pregnancy – increase incidence of
postpartum infection in women who engage in sex during the last 6 weeks

Exercises
 Important during pregnancy to prevent circulatory stasis in the lower extremities and to strengthen the
muscles used in labor and delivery; it also offer a general feeling of well-being

 Should be done in moderation

 Exercise Programs:
o Exercises that target large muscle groups rhythmically – e.g. walking, are best
o Intensity of exercise program depends on the woman’s cardiopulmonary fitness
o Before any exercise program – woman must consult her physician or nurse-midwife
o If any complication of pregnancy occurs – e.g. bleeding or PIH – discontinue until she rechecks
w/ primary health care provider about continuing

 Exercise shd be individualized – accdng to age; physical condition; customary amount of exercise (e.g.
swimming, tennis), not C/I unless done the first time; stage of pregnancy

 Swimming may help relieve backache

o Membranes shd be intact

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 Recommended exercises:
1. Squatting and tailor-sitting
 help stretch and strengthen perineal muscles
 increases circulation in the perineum
 make pelvic joints more pliable/flexible
 when standing from the squatting position – raise buttocks first before raising head to
prevent postural hypotension

2. Pelvic rock
 maintain good posture
 relieves abdominal pressure and low backaches
 strengthen abdominal muscles following delivery

3. Modified knee-chest position

 Relieves pelvic pressure and cramps in the thighs and buttocks

4. Shoulder circling
 Strengthens the muscles of the chest

5. Walking – BEST EXERCISE

 Shd be encouraged to take daily walks unless bad weather, many levels of stairs or unsafe
neighborhood will not permit

6. Kegel
 Relieves congestion and discomfort in pelvic region
 Tones up pelvic floor muscles

Sleep
 The optimal condition for body growth occurs when growth hormone secretion is @ its highest level –
that is, during sleep

 This, plus overall increased metabolic demand of pregnancy – appears to be the physiologic reason
pregnant women need an ed amount of sleep or @ least rest to build new body cells during pregnancy

 Pregnant women rarely have difficulty falling asleep @ night

o Trouble falling asleep – drink a glass of warm milk may help
o Relaxation techniques – lying quietly, systematically relaxing neck muscles, shoulder muscles,
arm muscles, and so on = may also be effective

 Late in pregnancy – awakening @ short, frequent intervals by the activity of the fetus
o Leads to loss of REM sleep
o On rising, may feel anxious or not well-rested

 May also awaken w/ pyrosis or dyspnea, if she has been lying flat – sleeping on 2 pillows or on a
couch w/ an armrest may be helpful

 Rest period during the afternoon and full night of sleep – needed to obtain enough sleep and rest
during pregnancy

 Modified Sim’s position w/ top leg forward – good resting or sleeping position
o Puts weight of the fetus on the bed, not on the woman, and allows good circulation in the lower
extremities

 Avoid resting in a supine position – prevent supine hypotension syndrome

 Avoid resting w/ knees sharply bent either when sitting or lying down – minimize risk of venous stasis
below the knee

Employment
 Not C/I unless it entails:
 exposure to toxic substances

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  lifting heavy objects
 other kinds of physical strains
 long periods of standing
 or having to maintain body balance

 Advise to walk about every few hours to break long periods of standing or sitting to promote circulation

Travel
 Early in a normal pregnancy – no travel restriction
o Susceptible to motion sickness – shd not take any medication unless specifically prescribed or
approved by physician or nurse-midwife

 Late in pregnancy – travel plans shd take into consideration the possibility of early labor, requiring birth
@ a strange setting where woman’s health history will be unknown

 Advise a woman taking long trip by automobile:

o Plan for frequent rest or stretch periods q hour
o Q 2h, shd get out of the car and walk short distance – relieve stiffness and muscle ache; improve
lower extremity circulation = preventing varicosities, hemorrhoids and thrombophlebitis

 Traveling by plane – not C/I; as long as plane has a well-pressurized cabin

o Some airline do not permit women who are more than 7 months pregnant
o Others require written permission from woman’s primary care provider
o Advise to inquire about these restrictions by calling airline

 Advise additional immunizations (cholera vaccines) if traveling internationally

o All live virus vaccines (measles, mumps, rubella, yellow fever) – C/I during pregnancy, and shd
not be administered unless risk of disease outweighs risk to the pregnancy

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