LIU.

MAKAti
Maternal& ChildHealthNursing:
NursingCarein the Antepartalperiod

DIAGNOSIS
OF PREGNANCY
PresumptiveSigns

- lessindicativeof pregnancy
- takenassingleentities
- couldeasityindicateotherconditions
- largetySUBJECTTVE

Probable Signs

- canbe documented by the examiner

- atthoughmorereliabtethanthe presumptive
signs,
they are still not positive or true diagnostic
of pregnancy

Positive Signs Serumlab.tests

Breastchanges
- there are onty three positive signs: Morningsickness
- fetal hearth tones Amenorrhea
- fetal movement felt by the examiner Urinaryfrequen-
- ultrasound evidence of the fetus cy
Chadwick'ssign
Goodeltlssign
Hegar'ssign
Sonographic
evidence of
gestationaI
5ac

Sonographic
evidence of
fetal out-
line
Fetal heart
audibte
Fatigue
Entarging
uterus
Batlotement
Quickening
Fetalmove-
mentfett
by examiner
BraxtonHicks

MarlonBernardo,RN

b. Constipation andflatulenceare dueto disptace-
mentof stomachandintestines,thusslowing
peristalsisandgastricemptyingtime; mayatsodue
to increased progesteronewhichinhibitsgastric
motitity.
> Increasedfluids and roughagein the diet.
> Establlsheliminationtime.
> Avoid enemas- may lead to habit forming.
> Alineraloil shouldnot be taken becauieit
interferes with the absorptionof fat-soluble
vitamins(ADEK),
c. Hemorrhoids are dueto pressureof entargeduterus
on the intestine.
> Coldcompress(promotesyasoconstriction).
3. Respiratory
a. Shortnessof breath due to:
- increasedO, consumptionand production of
CO2by the product of conception during the
first trimester.
- increased uterine size causesthe diaphragm to
be pushedor displaced, thus crowding the
chest cavity,
> Lateral expansion of the chest to compensate
for shortness of breathing increases O, supply
and vital lung capacity.
5. llusculoskeletal
a. Because of the woman'sattemptto changeher
center of gravity,shemakesambutationeasierby
standingmorestraightandtatler (LORDOS|S/ PRIDE
OFPREGMNCY). Dueto productionof relaxin,
petvicbonesbecomemoremovable,increasing the
incidence of accidental falts due to the whobty
> Adviseto use low-heeled shoes
b. L€g cramps are causedby:
- increasedpressureof the graviduteruson the
lowersxtremities.
- fatigueandmuscletenseness.
- tow catciumtevel in the body.
MarlonBernardo,RN
Matemal& ChildHealthNursing:
NursingCarein the AntepartalPeriod
d. Heart burn, especially in the last trimester, is due
to.increased progesterone which decreased gastric
motitity, thereby causingreverse peristaltic waves.
This leads to regurgitation of acid in the stomach
into the esophagus,causingirritation.
> Avoid fried or fatty foods.
> Sips of milk at frequent intervals.
> Small frequent meals taken slowly.
> Bend at the knees, not at th€ waist.
> Take antacids. NEVERsodium bicarbonate
(alkaseltzer or baking soda becau5e they
promote fl uid retention),
4. Urinqry
a. Urinaryfrequenryis seenduringthe 1rt and3rd
trimesters.
- 1sttri is dueto increasedbloodsupplyin the
btood.
- 3d tri is dueto pressureof entargeduteruson
btadderespeciatty duringtigthening.
b. Decreasedrenal treshold for stgar becauseof the
increasedproduction of glucocorticoidsthat cause
lactose and dextrose to spi[[ into the urine of
pregnant women (glycosuria).
' Since alt pregnant women have sugar in their
urine, it woutd be difficutt to diagnosediabeteg
mettitus in pregnancybasedon the urine sampte
atone.
> Frequent rest periods with legs elevated.
> Increase calcium intake-
> Do not massage legs.
> Press knob of the affected leg and dorslflex
foot.
Temperature
Slightincreasein basalbodytemperaturedueto
increasedprogesterone,but the bodyadaptsafter the
4h monthof pregnanry.
7. Endocrine
a. Ptacentaproduces hCG,HLBestrogen,and
progesterone.
b. ,{oderateentargement of the thyroidglanddue
to hyperptasia
of the grandulartissuesand
increasedvascutarity.
 CEU-Makati
b. Constipation andftatulenceare dueto disptace-
mentof stomachandintestines,thusslowing
peristalsisandgastricemptyingtime; mayatsodue
to increased progesteronewhichinhibitsgastric
motility.
> Increasedfluids and roughagein the diet.
> Establlsheliminationtime.
> Avoid enemas- may lead to habit forming.
> Alineraloil shouldnot be taken becauieit
interferes with the absorptionof fat-soluble
vitamins(ADEK).
c. Hemorrhoids are dueto pressureof entargeduterus
on the intestine.
> Coldcompress(promotesvasoconstriction).
3. Respiratory
a. Shortnessof breath due to:
- increasedO, consumptionand production of
COzby the product of conception during the
first trimester.
- increased uterine size causesthe diaphragm to
be pushedor disptaced, thus crowding the
chest cavity.
> Lateral expansion of the chest to compensate
for shortness of breathing increases O, supply
and vital lung capacity.
5. llusculoskeletal
a. Because of the woman'sattemptto changeher
center of gravity,shemakesambutationeasierby
standingmorestraightandtatler (LORDOS|S/ PRIDE
OFPREGMNCY). Dueto productionof relaxin,
petvicbonesbecomemoremovable,increasing the
incidence of accidental fatts due to the whobty
> Adviseto use low-heeled shoes
b. L€g cramps are causedby:
- increasedpressureof the graviduteruson the
lowersxtremities.
- fatigueandmuscletenseness.
- tow catciumtevel in the body.
MarlonBernardo,RN
Matemal& ChildHealthNursing:
NursingCarein the AntepartalPeriod
d. Heart burn, especially in the last trimestet is due
to.increased progesterone which decreased gastric
motitity, thereby causingreverse peristaltic waves.
This leads to regurgitation of acid in the stomach
into the esophagus,causingirritation.
> Avoid fried or fatty foods.
> Sips of milk at frequent intervals.
> Small frequent meals taken slowly.
> Bend at the knees, not at the waist.
> Take antacids. NEVERsodium bicarbonate
(alkaseltz€r or baking soda becau5e they
promote fl uid retention),
4. Urinqry
a. Urinaryfrequenryis seenduringthe 1rt and3rd
trimesters.
- 1sttri is dueto increasedbloodsupplyin the
btood.
- 3d tri is dueto pressureof entargeduteruson
btadderespeciatty duringtigthening.
b. Decreasedrenal treshold for sugar becauseof the
increased production of glucocorticoids that cause
lactose and dextrose to spi[[ into the urine of
pregnant women (glycosuria).
' Since all pregnant women have sugar in their
urine, it woutd be difficutt to diagnosediabeteg
mettitus in pregnancybasedon the urine sampte
a{one.
> Frequent rest periods with legs elevated.
> Increase calcium intake-
> Do not massage legs.
> Press knob of the affected leg and dorslflex
foot.
Temperature
Slightincreasein basalbodytemperaturedueto
increasedprogesterone,but the bodyadaptsafter the
4h monthof pregnanry.
7. Endocrine
a. Ptacentaproduces hCG,HLBestrogen,and
progesterone,
b. i{oderateentargement of the thyroidglanddue
to hyperptasiaof the grandutartissuesand
increasedvascutarity.
 cEU-Makati
Weight
a. Averageweight gain is 24-30 pounds, comprised of:
- Fetus: 7 lbs
- Amniotic ftuid: 2 lbs
- Placenta and membranes: 1 14lbs
- Uterus: 2 ,,1lbs
- Breast: 3 lbs
- Increasedblood volume: 2-4 lbs
- Extravascularftuid and fat: 4-9 tbs.
b. Water retention, about 7 titers, commontyoccurs
during pregnancy.
- Fetus, placenta and amniotic fluid: 3,5 liters
- Increasedblood volume, interstitiat fluid, and
hypertrophi€d maternal organs: 3.5 liters
2. Yagina
a. Increasedvasarlarity causeschange cotor from
tight pink to deep purpte or violet known as
Chadwick's sign.
b. pH of the vagina changesfrom acidic to alkaline
becauseof estrogen. lt protects the vaginal
environmentfrom bacteria,but favorsthe
of trichomonas- a protozoaor flagettate.tt witt
TCSUIItO TRICHOAAONAS VAGINALISOr
TRICHOI,IONAS VAGlNlTlSor TRtCHOilONtAStS.
S/5: - frothy, cream-colored, irritatingty itchy
and foul smetling discharge.
- vulvutar edema and hyperemia secondary
to irritation from discharges.
3. Ovories
Do not produce ova during pregnancy.
4. Ahdonpn
a. Striae gravidarum - increaseduterine size
results in rupture and atrophy of connective
tissue layers, seen as pink or reddish streaks.
b. Umbilicusis pushedout.
MarlonBernardo,RN
Maternal& ChildHeahhNursing:
NursingCarein the Antepartalperiod
LocalChanges
1. Uterus
a. Changein shape pear like to ovoid.
b, Changein consistencyof lower uterine segment
causes extreme softening known as Hegar's sign,
seen at about 6 weeks gestation.
c. Mucusptugs in the cervix, catted operculum, are
produced to seal out the bacteria.
d. CeMx becomesmore vascutarand edematous
resembtingthe consistencyof the eartobe known
as Goodel's sign.
e. Eraxton Hick's contractions (painless
contractions) occur intermittentty throughout
pregnancy,and can be fett by the mother by the
4B month.
Treatment:
' Ftagyl(metronidazote) or vaginatsupptement of
trichomonicidatcompounds (ex. Tricofuron,
Vagisoc,andDevogan).
> Treatmalepartneraswe[[,
> Avoidintercoursetd preventreinfection.
lvlONlLfASlS causedby fungusCondidaalbicans. Also
cattedCANDIDIASIS.
S/S: - white, patchy,cheeze-tike partictesthat
adhereto vaginalwatts.
- irritatinglyitchy,andfoul smetlingdischarges.
Treatment:
> /r4ycostatin/l,lystatin
> Ayoidintercourse.
. Monitiasis
is seenasoral thrushin the newborn
whentransmittedduringdeliverythroughthe
birth canalof the infectedmother.
5. Skin
a. Lineanigra- brownline runningfrom the
umbiticusto the symphysis pubis. '
b. Chloasma - extrapigmentation of the cheeksand
acrossthe nosedue to increasedproductionof
metanoqftes by the pituitarygland. lGrownasthe
MASKOFPREGMNCY.
6. Ereast
a. Estrogencontributesin the deve{opment
of the
breastin preparationfor [actation.
b. Nipptesare moreere€t,areotabecomes darker
andlarge6andcolostrumis formed.
 CEU-Makati
PSYCHOLOGICALTASKS
OF
PREGNANCY
First Trimeiter (Accepting the Pregnancy)
The fetus is an unidentified concept with a great
future imptications but without tangibte evidence of
reality. Somedegree of rejection and disbetief, deniat
and depression. lilother is ambivalent.
> When giving health teachings, emphasize the
bodily changes in pregnancy.
THEPRENATAL
VISIT
The provision of.prenatal care is the
primary focus in the improvement of
matemal and infant morbidity and mortatity
rateg. To ensurethe successof prenatal care
programs,it shoutdbe rememberedthat the
client's understandingof the modatities of
care is basic to cooperative action among
health professionalsand pregnant woman
and her famity.
Abortion is the medical term for any pregnancy
terminated before the age of viabitity.
'Age of viability - the earliest age at which fetuses
coutd survive if they were born at that time,
generallyacceptedas 24weeks,or fetusesweighi
morethan400g.
' Today'spracticeaccepts20 weeksas the ageof
viabitity.
Terms related to preqndnc'r status:
Primigrovida - pregnant for the first time
Primipara - has given birth to one chitd past age of
viabitity
Itultigravida - has been pregnant previousty
llultipara - has caried two or more pregnanciesto
viabitity
Nulligravida - never been and is not currenttv
pregnant
MarlonBernardo,RN
Maternal& ChildHealthNursing:
NursingCarein the Antepartalperiod
kcond Trimester (Accepting the Baby)
Fetus is perceived as a separate entity. Fantasized
the appearanceof the baby. Irlother accepts pregnancy.
Third Trimester (Preparing for Parenthood)
Has personal identification with a real baby about to
be born and reatistic plans for future child care
responsibilities. This is the best time to tatk about
infant feeding method. Fear of death is prominent.
> Let the woman listen to the fetal heart sound.
1. HistoryToking
a. Personat Data
b- ObstetricalData GP(IPAL)
Gravida- numberof pregnancies a womanhas
Para- numberof viabtepregnancyregardtessof
numberandoutcome.
TPALscore- numberof fu[[ Termbabies,
Prematuredeliveries,Abortions,Livingchildren.
Ti infantsbornat 37 weeksor after
P: infantsbornbefore37weeks
A: spontaneous or inducedabortions
L: tivingchitdren
* ln USsetting,lt (muttiptepregnancies)
is alsotaken
aspart of the obstetricaldata - GP(TPALM).
Mrs. Bemardois pregnantfor the sixth time.
Sheis seenfor her first prenatal check-up.
Shereported that she has a girl born at 35
weeks; 2 boys, both born at 39 weeks; and a
twin born at 37 weeks, Shealso noted that
she had one miscarriageat 18 weeks. Using
the GP(TPAL) systemto describeMrs.
Bernardo's,current obstetrica[ history the
nursewoutd record:
G6P4(3-1,1
-5)
 CEU-Makati Maternal& ChildHealthNursing:
llursingCarein the AntepartalPeriod

\
A pregnantwomanis seenfor her Zndprenatat Awoman is pregnantfor the secondtime. Her
check-up. Sheretated that she has4 first pregnancyendedin a spontaneous
children, Shehas a boy born at 35 week, a abortion at 12 weeks. The correct term to
girl born at 37 weeks, and a fratemat twin
useto describethis woman'sobstetrical
bom at 40 week. Sheaddedthat she had a historywoutd be:
miscarriageat 12 weeks. Usingthe
GP(TPALM) system,the nursewould record:

Multigravida,nutlipara
G5P3Q-1-1-4-1)

Aside from the GP (TPAL),the nurse shoutd also ask fo

Past preenancies
- method of delivery?
- where?
- risk invotved?
Present pregnan(t!
- chief concern
Dancer Sienak
- yaginal bteeding no matter how stight
- swetting of face and fingers
- severe and continuous headache
- dimnessor bturring of vision
- flashing of light or dots before the eyes
- persistent vomiting, chitts, and fever
- suddenescape of ftuid from the vagina
- absenceof fetal heart soundsafter they have been
auscuttated on the 4s and 56 month.
Medicat Data
2. Assessment
a. PhysicalExam
Reviorof systemii indicated,inctuding
inspectionof teeth becausethey are commonfoci
infection.
b. Petvic Exam (Cardinal rule: Empty bladder firstt)
- Internal Exam (lE) to determine Chadwicks,
Goodett'sand Hegar'ssigns.
' Ballotement - fetus will bounce when tower
uterine segment is tapped on the 5s month.
- Pap Smear (PapanicotauSmear)- cytotogical
study to diagnosecervical carcinoma.

- C[assificationof findings in Pap Smear: - Petvic measurementsare done after the 56

Ctass1 - absenceof abnormal celts month through X-ray pelvimetry, This
Class2 - presenceof atypical cytotogy, but no preferabty done 2 weeks before EDBto
evidence of matignancy determine CPD(cephato-petvicdisproportion).
Class3 - q/totogy suggestiveof malignahcy
Ctass4 - cytotogy strongty suggestive of - Leopold's }lan€uver - done to estimate fetal
matignancy size, [ocate fetal parts, and determine
Ctas 5 - cytology conctusiveof ma[ignancy presentation, position, engagement, and
attitude.
- Clinicol Stqq*: reftects {ocalization or spread of
malignant cervical changes
Stage 1 - CA confined in the cervix
Stage2 - CAextends into vagina, but not in the
petvic walt
Stage3 - metastasisin the petvic wall
Stage 4 - metastasis beyond petvic wa[[ into
bladder and rectum

MarlonBernardo,RN
 CEU-Makati Maternal& ChildHealthNursing:
NursingCarein the Antepartalperiod

> lnstruct to empty btadder. lit (Fundalgrip): Facingthe headpart, palpatefor

> The examiner, based on his/her dominant hand,
should position on that side of the mother (A
teft-hand dominant examiner shoutd oosition on
the left side of the mother).
> Ptacethe mother in dorsa( recumbent, to retax
the abdominaI muscles{knees stighttyftexed).
> Place a rolted towel or smatl pillow under the
right side of the trunk to prevent supine
hypotensive syndrome.
> Warm hands before palpating (cotd handscause
muscle tightening).
> Use the finger pads in palpating.
fetal part in the fundus.
2d (Umbilicalgrip): Palpatesidesof the uterusto
determinelocationof fetal back.
3rd(Pawlick'sgrip): Grasplowerportionof the
abdomenjust abovesymphysis pubisto
determinedegreeof engagement.
4tr: Facingthe feet part, crossfingersdownward
on bothsidesof the uterusabovethe inguinal
tigamentsto determineattitude,

c. Vital Signs ESTIMATES

OF PREGNANCY
TPRare important during the initiat visit. The 1. Nagele's Rule
most important are BPand weight to serve as
basetinedata during visits. calcutation of EDB(estimated date of birth) or
EDD(estimated date of detivery). Get the Wp
d. Urine Examination (first day of the last mestrual period), count back 3
months and add 7 days.
Albumineria - ideally negative. Presenceof this
must be reported becauseit is a sign of Z. AlcDonald's Rule
toxemia.
Pyuria - signsof UTl. UTI is the most common
cause of premature delivery.
Glycosuria - specimen shoutd be taken before
breakfast to avoid false positive resutts.

3. Bartholomew's Rule

estimates AOG (age of gestation) by the re{ative The first day of woman's last menstrual period
position of the uterus in the abdominal cavity was May 3, 2008 and it ended May 7. Using
Nagetek rule, this woman's estimated date of
3d month - fundus is stightty above the symphysispubis birth woutd be:
5b month - fundus is at the tevel.of umbilicus
9b month - fundus below the xyphoid process
86 and lOh monffis - same [eve[ because of t.igthening

4. Haase's Rule February10,2009

calcutation of the feta[ l'ength in cm. For the

first 5 months, square the month; 6 - 10 months,
muttipty by 5.
CEU-Makati
After measuringa woman'sfundus,a nllrse
usedMcDonatd's ruteto estimatethe
gestationalageof the pregnancy in weeks..
Sincethe woman'sfundatheightwas24 cm,
the gestationat
ageof the pregnancy woutdbe
approximatetyhowmanyweeks?
\ estimation of adequate weight gain.
Vitaminsand minerals:
. Protein- for buitdingup of fetal tissue
. Vit. C - for bloodctotting activity of the mother
andfetus,whichenhances the productionof
capittaries,therebyenhancing orygenation
necessaryfor tissuegrowthandwoundheating.
. .Catcium- necessary for lactation.
. lron-richfoodsare especiatty importantduringthe
lasttrimesterfor the fetusto haveenoughiron
storesto last him for 3 monthsof infancywhen
intakeis main(ymilk (deficientin iron).
d. Steep
> lf a woman has troubte steeping, drinking a
glass of warm milk may help. Relaxatlon
exercises also may be effective.
> Avold restlng in a supine position to prevent
supin6 hypotensive syndrome.
e. Exercise
- Exerciseduring pregnancyis important to
prevent circulatory stasis in the tower
extremities. Also, to strengthen the muscle
used in tabor and delivery.
> Walking is the best exercise during
pregnancy, and women should be
encourag€d to tak6 a deily walk.
MarlonBernardo,RN
Matemal& ChildHealthNursing:
NursingCarein the AntepartalPeriod
HEALTHPRO,TAOTION
ACTIVITIES
DURINGPREGNANCY
a. Nutrition
- currentty recommended as an average
weight gain in pregnancyis 25 to 40 tbs.
- Body massindex (BMl) is a more precise
- Womenwho need speciat attention are
pregnant adolescent, underweight, obese,
low income, veg€tarians.
b. Bathing
> daily tub baths or showers are recommended.
During pregnancy, sweating tends to increase
because the woman excretes waste products
for herself and the fetus.
c. Dressing
> pregnantwoman should avoid garters, extre-
mely firm $rdles with panty legs, and knee
high stockings because these may impede
lower-extremity circutation.
> suggest wearing 3hoes wlth a moderate to low
heel to minimize pelvic titt and possibte
backache.
f. Travel
- Earty in a normat pregnancy,there are no
restrictions. Late in pregnancy, travel ptans
shoutd take into consideration the possibility
of early labor.
g. SexualActivity
- sexual desires continue during pregnancybut
level changes.
' 1it tri: decreased;woman is preoccupied
with the changesin her body.
' 2d tri: increased; woman has adapted to
pregnancy.
3d tri: decreased;woman is afraid of hurting
the fetus.
CEU-Makati
h. Work
- Cautionwomanwhosejobs invotveexposure
lifting heaw objects,
to toxic substances,
otherkindsof excessive physicatstrain,long
periodsof standing,or havingto maintain
bodybalance.
l. DentalCare
- Gingivaltissuetendsto hypertrophy during
pregnancy (pocketsof ptaqueform readily
betweenthe entargedgumtineandteeth).
> Encouragesnakcingon nutritlous foods,
suchasfresh fruits and.vegetablesto avoid
sugarcomingin contactwlth teeth.
Marlon Bernardg,RN
Maternal& child HeatthNursing:
NursingCarein the AntepartalPeriod
J. Breast Care
> Ageneral rule is to wear a firm, supportive
bra with wide straps to spread welght across
the shouldeF.
- Colostrum sxretion begins at about the 166
week of pregnancy. Instruct to wash her
breast with clear tap water daily to remove
the colostrum, thus minimizing the rkk of
infection. Constant moisture next to the
breast nipple may cause nipple excoriation,
pain, and lissurirg.
 CEU-Makati
LABORATORY
EXAMS
1. Urinary PregnancyTest
- presence of hCGin the urineis the basisfor
positiveresult. hCGis pr€Bentfrom 40s dayto the
100s day of pregnancy, reaching the peak levet on
60h day. hCG therefore is most correct 6 weeks after
LJ\{P.When cottecting urine for pregnancytest:
> NPOpost 8 pm to concentrate urine
> Flrst morning urine, midstream catch should be
collected.
> hCGis unstable under room temperature;
refrigerate prn.
CHANGES
OF PREGNANCY
SystemicChanges
1. Cdrdiovascular or Circulatory
a. Beginningthe end of the 1't trimester, there is a
gradua[ increase of 30%-50%in total cardiac
volume reaching its peak during the 6s month of
pregnancy. This causesa drop in hemoglobin and
hematocrit tevels (physiological anemia of
pregnanry or pseudoanemia).
- edema of the tower extremities occur
> Ralse legs above the hip level.
" Edema of the lower extremities is NOT a sign of
toxemia.
- varicosities of the lower extremities can occur
> Use/wear elastic stockings to promote varicose
flow thus preyenting stasis in the lower ext.
> Elastic bandage should start from the distal end
the extremityand work towardthe trunk to
congestionand impairedcirculationat the distal
part.
> Avoid useof constricting garters.
d. Because of poorcircutationin the btoodvessels
of
genitatiadueto pressure of the graviduterus,
varicosities
of the vutvaandthe rectumappear.
> Side-lying position with hips elevated on
MarlonBernardo,RN
Maternal& ChildHealthNursing:
NursingCarein the AntepartalPeriod
2. Progesterone Withdrawal Test
- a contraceptive pitl is taken OD or TID x 3 days.
lf menstruation
occurwithin 10to I 5 days,the
is not pregnant. lf pregnant, the corpus tuteum
produces enough hormones to neutralize the effect of
withdrawn synthetic progesteroneand no bteeding
occurs.
Consequences
of increasedcardiocvolume:
- easyfatigabilityandshortnessof breathdueto
increasedcardiacworktoad
- epistaxis/nosebteeding- dueto increased
of the nasopharynx
b. Patoitationsdueto increasedpressure
of uterus
againstthe diaphragmduringthe secondhalf of
pregnancy,
c. Because of poorcirculationresuttingfrom pressure
the graviduteruson the btoodvessets of the tower
extremities:
2. Gastrointestinal
a. Morning sickness(nauseaand vomiting during
pregnancy) is due to increased hCG, increased
production of gastric acid (heart burn) or due to
emotionaI factors.
> Eat dry toast or crackers 30 mlnutes before
arising In the moming.
> Encourage to eat dry high carbohydrates, low
fat, and low spices in the diet.
' Flvperelnesis erovidorum - excessive nausea and
vomiting which persists beyond 3 months may
result in dehydration, starvation and acidosis.