Prenatal Management

References:

1. Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (Ch. 5, pp. 96–98)

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Prenatal checkups are done to improve maternal and neonatal outcomes. It aims to define the health status of the mother and fetus, the gestational age of the fetus and the estimated date of confinement (EDC), initiate a nursing care plan for continuing maternity care for both the mother and the fetus, and detect any high-risk conditions early. The first visit should be held as soon as the mother misses a menstrual period when pregnancy is suspected. Following this, the schedule of visits are:

Trimester	DOH (4 total visits)	WHO (14 total visits)	RPS (14 total visits)
1st Trimester	Once before the fourth month	Once a month	Once a month
2nd Trimester	Once before the sixth month	Once every two weeks	Once a month
3rd Trimester	Once before the eighth month	Once a week	Once a month (to 8th month), then twice a month for the third month
Final Month	Once on the final month	Once	Once a week on the final month (36th to 40th week)

Frequency increases if danger signals are present, or if known risk factors are established.

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Conducting Visits

Prenatal visits are done to serve as a basis for comparison (baseline data collection) with information gathered on subsequent visits. These function to screen for risk factors during pregnancy. For the initial visit, obtain the woman’s:

1. Obstetrical History:
   • Menstrual History: menarche, regularity, duration, frequency, character
   • Last Menstrual Period, Sexual History, and Methods of Contraception
   • Past Menstrual Period
2. Medical and Surgical History: past illnesses, surgical procedures, and drugs currently being used.
3. Family History: to detect illnesses or conditions that are transmissible or hereditary.
4. Current Problems: activities of daily living, discomforts, danger signs.
5. Vital Signs: temperature, cardiac rate, respiratory rate, blood pressure
   • Temperature becomes elevated by progesterone and basal metabolic rate, not to reach 38°C.
   • Cardiac rate increases by 10 to 15 BPM during pregnancy.
   • Respiratory rate at rest can increase to 24 respirations/min.
   • Blood pressure is rarely affected, but hypotension can occur due to supine hypotension syndrome/vena caval syndrome. Prevention of this syndrome is through the use of a left-lateral recumbent position. Pregnancy-Induced Hypertension (PIH)is an important problem of pregnancy.
     • The roll-over test can be done in the first trimester for early detection of developing PIH by 20 to 24 weeks. Place the mother in the LLR position, check BP until stable (may take 10 to 15 minutes), then roll to supine. Check BP right away, then again in 5 minutes. If an increase between the two recordings exceeds 20 mm Hg, the woman is at risk (positive roll-over test).
6. Weight is checked every visit. Weight gain pattern should be monitored to determine any abnormalities. This is more important than the amount of weight gain; failure to gain weight is an ominous sign. The prepregnant weight is ideally from 90 to 150 lbs. Normal weight gain patterns contribute to the health of the mother and fetus. The total expected weight gain of 20 to 25, max of 35 lbs. is gained as follows:
   • First Trimester: 1 lb. every month, 3 to 4 lbs. in total
   • Second Trimester: 0.9 to 1 lb. every week, 10 to 12 lbs. in total
   • Third Trimester: 0.5 to 1 lb. every week, 8 to 11 lbs. in total.
7. Urine Testing: Benedict’s test (ideally at most 1+), Acetic Acid Test (should be negative)
8. Fetal Growth and Development Assessment
9. Obstetrical History: A.K.A. OB Scoring; a record of preceding pregnancies and perinatal outcomes. Multiple systems are used:
   • 4-Point System (FPAL):
     • Full-term: number of full-term births
     • Premature: number of premature births
     • Abortion: number of abortions
     • Living: number of currently living children
   • 5-Point System (GFPAL): the addition of Gravida (number of pregnancies) to the 4-Point system.
   • 7-Point System (GPTPALM):
     • Gravida: number of pregnancies
     • Parity/Para: number of deliveries—pregnancies that reach beyond the age of viability regardless of outcome.
     • Term: number of term deliveries
     • Preterm: number of preterm deliveries
     • Abortion: number of abortions (deliveries before the age of viability)
     • Living: number of currently living children
     • Multiple: number of deliveries of multiple fetuses
10. Estimates of Pregnancy
11. Age of Gestation
12. Complete Physical Examination
13. Laboratory Testing

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Complete Physical Examination

Internal Examination is done to detect early signs of pregnancy: Chadwick’s, Goodell’s, and Hegar’s sign. The following are the preparations for IE:

1. Explanation of the procedure
2. Voiding before IE
3. Proper positioning: Lithotomy; remember to set stirrups at equal height, avoiding pressure on the popliteal region, and to place legs on stirrups simultaneously.
4. Draping
5. Instructions for the patient: place the hands across the chest; correct breathing with slow, chest breaths.

WARNING

• Do not perform any activity that increases intra-abdominal pressure.
• Do not distract a woman’s attention from focused breathing/relaxation techniques.
• Avoid any impediment to communication.

Important concerns for physical examinations also include:

• Breasts: changes, adequacy for breastfeeding, or other abnormal signs
• Abdomen: fundal height, Leopold’s Maneuver
• Pelvimetry: done in the third trimester to determine potential cephalopelvic disproportion (CPD)
• Extremities: leg cramps, varicosities, pedal edema (discomforts), and Homan’s sign (calf pain upon dorsiflexion), a danger sign of pregnancy.

Leopold's Maneuver

Leopold’s Maneuver is a systematic abdominal palpation to estimate fetal size, locate fetal back and parts, and determine fetal position and presentation.

1. Explain the procedure and its purpose.
2. Position: dorsal recumbent with knees slightly flexed to relax the abdominal muscles.
3. Draping
4. Examining hands should be warm to avoid contractions of the abdominal muscles, which may impede palpation.
5. Apply gentle, firm palpations with the palms of the hands.

The steps are divided into four: 6. Palpate the fundus; check for breech or cephalic; usually breech— soft, globular, non-ballotable. 7. Palpate the sides of the abdomen; check for a smooth, resistant back and irregular, small fetal parts of the fetus. The area of the fetal back is the best site for FHT auscultation. 8. Palpate the area just above the symphysis pubis; check for cephalic or breech, usually cephalic; check the position and mobility of the head. 9. Palpate the midline downward and just about two inches from the Pourpart’s ligaments; check for position and descent of the head (engagement), including degree of flexion (attitude).

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Laboratory Tests

Preparing the Client

In all the necessary testing, the client should be prepared by:

1. Providing an explanation of the procedure.
2. Carrying out physical preparations specific to the procedure.
3. Providing support to the patient and spouse; encouraging verbalization of concerns.
4. Monitor the patient and fetus after the procedure.
5. Document as necessary.

1. Blood Studies:
   • Hemoglobin (12 to 16 g/dL) and hematocrit (37%–47%) are decreased in pregnancy.
   • Leukocytosis is not a sign of infection in pregnancy because the WBC count is normally elevated—it increases to 20,000/mm³ during labor and up to 25,000/mm³ postpartum.
   • Blood typing and Rh determination: If the mother is Rh negative, the first thing to be done is to determine paternal Rh; if the result is Rh positive, cord blood will be obtained at birth to determine the Rh of the baby’s blood. This is important for detecting the potential of isoimmunization.
   • Serology:
     • Syphilis (VDRL): Treatment for syphilis must be started immediately because placental protection only lasts for 16 weeks.
     • Rubella (Rubella antibody titer determination): if the ratio is 1:8 or less, there is an inadequate amount of protection against rubella, and so the mother should be immunized in the postpartum confinement. If the ratio is greater than 1:8, immunity is present, and there is no need for immunization.
     • Human Immunodeficiency Virus (HIV)
     • Hepatitis Screening as indicated
   • Alpha-fetoprotein screening at 16 to 18 weeks’ gestation to rule out neural defects.
   • Sickle cell trait screening if indicated (e.g., if of African descent).
2. Urine Tests: urine is tested for glucose (normally +1 in pregnancy) for the presence of gestational diabetes mellitus, and bacteria. Asymptomatic bacteriuria can result in abortion or premature labor.
3. Pelvic Laboratory Tests: pelvic cultures (Pap test, culture for gonorrhea and chlamydia) and bimanual examination to reveal cervical and uterine changes in pregnancy, detect uterine size, and assess for deviations in expected size and shape.