Antepartum

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Signs of Pregnancy

Presumptive

Period absent (amenorrhea)

Really tired

Enlarged breasts

Sore breasts

Urination frequency increased

Movement perceived (quickening)

Emesis & nausea

Probable

Positive pregnancy test

Return of fetus when tapped

Outline of fetus palpable

Braxton Hicks contractions

Asoftening of the cervix (Goodell’s sign)

Bluish color to the cervix (Chadwick’s sign)

Lower uterine segment softens (Hegar’s sign)

Enlarged uterus

Positive (FETUS)

Fetal movement felt by HCP

Eelectronic device detects fetal heart sounds

Tthe delivery of the fetus

Uultrasound detects the fetus

See movement the fetus (HCP)

Naegele’s Rule

The Naegele rule is a simple mathematical formula by which the estimated date of delivery (EDD) can be determined. The last menstruation period (LMP) is considered.

In the example in the image, the LMP for the woman was May 21, 2019. For this reason:

To find out the day: 21 + 7 days.
To calculate the month: 5 – 3 months.
As necessary, add one year.

The resulting EDD would therefore be Feburary 28, 2020.

GTPAL system for obstetric history notation

G	Gravida	The number of times a woman has been pregnant, regardless of pregnancy outcome Twins only count once! It was ONE pregnancy!
T	Term	The number of pregnancies delivered at 37 w 0 d gestation & beyond
P	Preterm	The number of pregnancies delivered from 20 w 0 d gestation through 36 w 6 d gestation
A	Abortion	The number of pregnancies ending before 20 w 0 d gestation; these may be spontaneous (miscarriage) or induced abortions
L	Living	The number of currently living children

Routine exams done for everyone

Blood type and Rh Factor

Important to know the mother’s blood type and if they is Rh positive or negative.
If the mother is Rh negative, and the baby is Rh positive, this is considered a ‘set up’ and puts the infant at risk for erythroblastosis fetalis.
Further testing needed if this is the case – after the baby is born.
- Direct Coombs test
  - Performed on the newborn’s blood sample
- Indirect Coombs test
  - Performed on the mother’s blood sample
Treatment = Rhogam

Glucose Challenge

Oral Glucose Tolerance Test

Done at 28 weeks
Mother drinks 50 grams of glucose in an oral solution
1 hour later her blood sugar is checked.
If the BG is greater than 140, the 3 hours glucose test is performed.

3 hour Glucose Tolerance Test

Done if the 1 hour test is failed or there are other risk factors.
It is done fasting; mothers must not eat or drink for 8 hours prior to the test.
A fasting sugar is checked
The mother drinks 100 grams of oral glucose.
Her BG is rechecked a 1 hour, 2 hours, and 3 hours.
A sugar greater than 140 indicates gestational diabetes.

Nonstress Test (NST)

This test assesses fetal well-being and oxygenation of the placenta
Evaluates if there are changes in the fetal heart rate with movement
- Increase in fetal heart rate with movement = acceleration = good
- Decrease in fetal heart rate with movement = deceleration = bad
  - This is a sign that the fetus will not tolerate labor.
Results
- Reactive
  - There are at least two accelerations of 15 beats per minutes for 15 seconds in a 20 minute period.
Non-Reactive
- There are NOT at least two accelerations of 15 beats per minutes for 15 seconds in a 20 minute period.
Further testing required if result is non-reactive

Contraction Stress Test

Preformed when the non-stress test is non-reactive.
Oxytocin is administered to induce contractions and the baby is monitored to evaluate their response to contractions.
Checking to see if the baby will tolerate labor, or show signs of stress.
Results
- Negative
  - Normal
  - The baby did not have decelerations in response to contractives
- Positive
  - Bad
  - The baby had decelerations indicating distress in response to contractions.

Vaccines during pregnancy

Recommended	Tdap Inactivated influenza Rho(D) immunoglobulin
Indicated for high-risk patients	Hepatitis B Hepatitis A Pneumococcus Haemophilus influenzae Meningococcus Varicella-zoster immunoglobulin
Contraindicated	HPV MMR Live attenuated influenza Varicella

High Risk Pregnancy Conditions

Hyperemesis Gravidarum

Extreme ‘morning sickness’
INTENSE, intractable, nausea AND vomiting during pregnancy

When to be concerned

Are they losing weight?
Are they dehydrated?
- Skin turgor
- Mucous membranes
- HR
Electrolytes
- Dehydration → hypernatremia
- Vomiting excessively → hypokalemia, hypochloremia

Dietary changes

Sit up after meals
Eat a few crackers before getting out of bed
Small portions
No liquids with meals; drink in between
Nothing spicy, too hot, or too cold…. Keep it simple

Medications

Promethazine
IVF
TPN/IL

Preeclampsia

20 weeks gestation
Blood pressure >140/90
2 times
4 hrs apart
Protein in the urine
Eclampsia – preeclampsia leads to seizures
New-onset hypertension, (SBP ≥140 mm Hg &/or DBP ≥90 mm Hg) at ≥20 weeks gestation, Proteinuria &/or end-organ damage

Severe features

SBP ≥160 mm Hg or DBP ≥110 mm Hg (2 times ≥4 hours apart), Thrombocytopenia↑, Creatinine↑, Transaminases, Pulmonary edema, Visual or cerebral symptoms

Management

Without severe features: delivery at ≥37 weeks, With severe features: delivery at ≥34 weeks, Magnesium sulfate (seizure prophylaxis), Antihypertensives

Assessment

Edema
- Hands
- Face
Weight gain
- Fluid
Headache
Abdominal pain
Blurry vision
Proteinuria

Therapeutic management

Delivery
Prepare for a preterm baby
- Mag sulfate → prevent seizures in mom
- Betamethasone → Help develop baby’s lungs
Antihypertensives

Antihypertensives during pregnancy

YES	NO
Labetalol	ACE-INHIBITORS
Nifedipine	ARBs, Can cause oligohydramnios, fetal growth restriction, and more!
Hydralazine

HELLP syndrome

Pathogenesis	Abnormal placental development, Maternal endothelial dysfunction
Clinical features	Hypertension, Right upper quadrant pain, Nausea/vomiting, Possible headache or vision changes
Laboratory findings	Microangiopathic hemolytic anemia, Thrombocytopenia, Elevated liver enzymes & bilirubin, Proteinuria

Gestational Diabetes

GDM – Gestational Diabetes Mellitus
Diabetes diagnosed during pregnancy
Pancreas unable to deal with the increased insulin requirements of pregnancy
- Increased insulin resistance secondary to hormones released during pregnancy
- Change in carbohydrate metabolism

Assessment

Screen for GDM at prenatal visits
- Glucose tolerance test at 24-28 weeks
Screen for glucose in the urine

Therapeutic Management

Control with diet and exercise
Monitor blood glucose
- Mother should not require insulin after delivery
- Neonate at risk for hypoglycemia
For baby
- Fetal pancreas produces its own insulin
- Was used to high levels of glucose in mothers blood
- After delivery, no longer has high glucose levels, but still producing that much insulin.

Ectopic Pregnancy

Ectopic = out of place
An egg is fertilized, but impants outside of the uterine cavity
- Fallopian tube
- Cervix
- Abdomen

Therapeutic Management

PREVENT rupture!!
- Detect with US
- Surgically removed
Methotrexate
- Stops the embryo from being able to grow
- Aborts the fetus
Rh immune globulin
- Given to mom if they is Rh negative
- Prevent erythroblastosis fetalis
  - Don’t know Rh type of fetus
  - Better safe than sorry!

Differential diagnosis of antepartum bleeding

Etiology	Common clinical features
Normal labor	Intermittent pain with contractions, small amount of blood-tinged mucus (“bloody show”)
Placental abruption	Sudden-onset vaginal bleeding, abdominal pain, hypertonic/tender uterus, tachysystole (frequent uterine contractions)
Placenta previa	Painless vaginal bleeding, ultrasound finding of placenta covering cervical os

Fetal Heart Rate Monitoring

Reassuring

Baseline heart rate in the normal range: 110-160
Moderate variability
Accelerations

Non-Reassuring

Fetal tachycardia – HR >160
Fetal bradycardia – HR <110
Decreased variability
Variable decelerations
Late decelerations

Nursing Interventions – Non-reassuring fetal heart rate (LION PIT)

L: Lay the mother on her LEFT side
I: Increase IV ﬂuids
O: Oxygen
N: Notify the primary healthcare provider
PIT: Discontinue Pitocin