Methods in Assessing the Fetal contraction monitors for 20
Well-Being min.
- Position: SEMI –
A. FETAL MOVEMENT (Kick FOWLERS
- SHORT-TERM
counts)
VARIABILITY – small
- Quickening – begins at 18 – 20
changes in FHB from
wks. AOG; peaks at 28 – 38 wks.
second to second
AOG
- LONG-TERM
- Average fetal movement = 10 –
VARIABILITY –
12x/ day
differences in FHR that
occur over 20 min
1. SANDOVSKY METHOD
2. NONSTRESS TESTING
➔ `- Counting & recording the
- Response of FHR to fetal
number of fetal movements in an
movement in which the
hour after a meal.
FHR and Uterine
➔ -Normal: 2x/ 10 min. or 10 –
Contraction Monitors are
12x/ hr.
attached.
➔ - Needs Referral: 10 fetal
- Position: SEMI-
movements in 2 hours.
FOWLERS/ LEFT
2. CARDIFF METHOD (Count-to-
LATERAL
Ten)
- Recording the time interval
it takes for the pregnant Normal: Abnormal
woman to feel the fetal
REACTIVE NON-
movement. NONSTRESS REACTIVE
- Normal: 10 fetal TEST NONSTRESS
movements/ hr. TEST
2 – 4 FHR No
B. FETAL HEART RATE
accelerations in 10 accelerations
- As early as the 10th – 11th wk min. with the fetal
- Normal: 120 – 160 beats/ min. movements
1. RHYTHM STRIP TESTING
3. VIBROACOUSTIC
- Determine the presence of
STIMULATION
good baseline rate, long &
- used to stimulate fetal
short-term variability by
movement by the use of
the use of external fetal
an acoustic stimulator
heart rate & uterine
especially if a
spontaneous acceleration ➔ Grade 0 = 12 – 24 wks.
has not occurred within 20 ➔ Grade 1 = 30 – 32 wks.
min. during NONSTRESS ➔ Grade 2 = 36 wks.
TEST. ➔ Grade 3 = 38 wks.
4. CONTRACTION STRESS
TESTING 4. AMNIOTIC FLUID
- Assessing FHR response VOLUME ASSESSMENT
to uterine contractions -The sum of the largest
pocket measurements of
Contraindication: amniotic fluid.
● Placenta previa - Average fluid
● Multifetal pregnancy index: 12 – 15 cm
● Incompetent cervix bet. 28 – 40 wks.
● Rupture of membranes
D. MATERNAL SERUM ALPHA-
C. ULTRASONOGRAPHY FETOPROTEIN
- To diagnose pregnancy as early Alpha-fetoprotein (AFP)
as 6 wks. - A substance produced by the
- To confirm the size, presence, & fetal liver that is present in
location of placenta & amniotic amniotic fluid and maternal
fluid serum.
- To establish the sex of the fetus - Increased MSAFP may result in
- To establish the presentation and spina bifida
position of the fetus. - Decreases MSAFP my result in
- To predict the maturity of the down syndrome
fetus.
E. TRIPLE SCREENING
1. BIPARIETAL DIAMETER 1. MSAFP
- - 8.5 cm. = 40 wks. Of 2. Unconjugated estriol
fetal age 3. hCG
2. DOPPLER UMBILICAL F. CHORIONIC VILLI SAMPLING
VELOCIMETRY - A biopsy & chromosomal or DNA
- Measures the analysis of chorionic villi was
velocity at which done at 10 – 12 wks. AOG
RBCs in the uterine
and fetal vessels G. AMNIOCENTESIS
and traveling. - An invasive procedure that
involves withdrawal of amniotic
fluid through the abdominal wall
3. PLACENTAL GRADING at 14th – 16th wk. of pregnancy.
- Can be found in the
1. L/S (Lecithin/sphingomyelin woman’s cervical mucus
ratio) early in pregnancy (fades
▪ These are the protein after 20 wks. AOG)
components of the lung enzyme
surfactant that the alveoli begin to 7. Inborn Errors of Metabolism
form at about 22nd – 24th wks. ● Cystinosis characterized
Pregnancy. by cystinuria (stone
formation in the urinary
2. Phosphatidyl Glycerol (PG) tract)
- Helps confirm fetal ● Maple syrup urine disease
maturity. ● Phenylketonuria
- Enzyme deficiency
3. Bilirubin level resulting in
- Indicates blood accumulation of
incompatibility or the phenylalanine & its
degree of destruction of metabolites in the
fetal RBCs in an RH blood causing
sensitized woman. severe mental
- A byproduct of RBC retardation.
breakdown
- If elevated: H. Percutaneous Umbilical Blood
Reflects release of Sampling (PUBS/ Cordocentesis or
bilirubin as excessive RBC Funicentesis)
begin their breakdown - Removal of blood from the fetal
umbilical cord (vein) at about 17
4. Creatinine wks.
A level of < 1.8 mg/dl
demonstrates maturing kidney I. Amnioscopy
function of the fetus. - Visual inspection of the
amniotic fluid through the
5. Chromosome analysis cervix and membranes
- Skin cells in the amniotic with an amnioscope.
fluid may be cultured and
stained for karyotyping. J. FETOSCOPY
- Visual inspection of the fetus
6. Fetal Fibronectin through a fetoscope that is
- A glycoprotein that helps inserted by amniocentesis
placenta attach to the technique in assessing fetal well-
uterine decidua. being.
K. BIOPHYSICAL PROFILE - The overall purpose of prenatal care
5 parameters: is to establish baseline data relevant
Fetal heart reactivity to a woman’s health and identify
- 2 or more accelerations of at health-promotion strategies.
least 15 bpm for 15 sec. over a
Frequency of Prenatal Check up
period of 20 min.
- First prenatal visit to 28th week of
Fetal breathing movements pregnancy - every 4 week
- 1 episode of 30 sec. of sustained - 29th - 36th week - every 2 weeks
fetal breathing movement within - Every week until due date.
30 min. of observation.
Fetal body movements 1st Prenatal Visit activity
- 3 separate episodes of fetal limb - Physical examination
or trunk movements within 30 - Obtaining blood and urine
min. specimens for laboratory analysis.
Fetal tone
- Fetus extends then flexes Terms related to pregnancy
extremities or spine of at least
a. Para- The number of pregnancies that
once in 30 min.
have reached viability, regardless of
Amniotic volume whether the infants were born alive
- Pocket of amniotic fluid b. Primipara- A woman who has given birth
measuring 1 cm in vertical to one child past age of viability
diameter. c. Multipara- A woman who has carried two
or more pregnancies to viability
Score: d. Grand multipara- A woman who has
8 – 10 fetus is doing well; healthy fetus carried five or more pregnancies to viability
e. Gravida- A woman who is or has been
pregnant
6 - suspicious; requires determination of
f. Primigravida- A woman who is pregnant
the need
for the first time
g. Multigravida- A woman who has been
for immediate delivery of the fetus, pregnant previously
considering maturity of the fetal lungs. h. Nulligravida- A woman who has never
been and is not currently pregnant
4 - fetus in jeopardy
Chapter 11 Nursing Care Related to Classification of pregnancy status
GTPAL/GTPALM.
Assessment of a Pregnant Family
G: number of times the woman has
The overall purposes of prenatal care
been pregnant
T: the number of full-term infants born Anthropoid, or “ape-like,” pelvis, the
(infants born at 37 weeks or after) transverse diameter is narrow; the
P: the number of preterm infants born anteroposterior diameter of the inlet is
(infants born before 37 weeks) larger than usual.
A: the number of spontaneous
miscarriages or therapeutic abortions Platypelloid, or “flattened,” pelvis has
L: the number of living children a smoothly curved oval inlet.
EDD/EDC of the pregnant client using
Naegel’s Rule
CHAPTER 10 Physiologic Changes of
- Add seven days to the first day of Pregnancy
your LMP and then subtract three
months.
- Note: Add 1 year if mag start Presumptive Sings and Symptoms of
ang month sa May
Pregnancy
Measurement of Fundal Height - Presumptive signs and
symptoms of pregnancy are
12 to 14th weeks those signs and symptoms
- Uterus beocmes palpable as firm that are usually noted by the
as sphere showing over the patient.
symphysis pubis. - These signs and symptoms
20 to 22 weeks are not proof of pregnancy
but they will make the
- Grows to reach the umbilicus.
physician and woman
36th weeks suspicious of pregnancy.
- The xiphoid process
Different types of pelvis and the 1. Amenorrhea (Cessation of
pelvic measurements Menstruation).
- One of the earliest clues
Gynecoid, or “female,” pelvis has an of pregnancy.
inlet that is well rounded forward and
2. Nausea and Vomiting (Morning
backward and has a wide pubic arch. Sickness)
- Usually occurs in the early
Android, or “male,” pelvis, the pubic morning during the first
arch forms an acute angle, making the weeks of pregnancy.
lower dimensions of the pelvis extremely
narrow. - Usually spontaneous and
subsides in 6 to 8 weeks
or by the twelfth to
sixteenth week of
pregnancy. 6. Quickening (Feeling of
Hyperemesis gravidarum Life)
- This is referred to as - The first perception of fetal
nausea and vomiting that movement within the uterus.
is severe and lasts beyond ○ It usually occurs toward the
the fourth month of 18th week.
pregnancy. ○ A multigravida can feel
3. Frequent Urination quickening as early as 16
- caused by the pressure of weeks.
the expanding uterus on ○ A primigravida usually cannot
the bladder. feel quickening until after 18
weeks.
4. Breast ChangesBreast 7. Skin Changes
Changes A. Striae gravidarum
- slight, temporary (Stretch Marks)
enlargement of the - These marks are
breasts, causing a caused by
sensation of weight, increased
fullness, and mild production or
tingling. sensitivity to
adrenocortical
The patient may notice hormones during
the ff: pregnancy
Darkening of the areola -- the B. Linea Nigra
brown part around the nipple. - This is a black line
○ Enlargement of in the midline of the
Montgomery Glands -- the abdomen that may
tiny nodules or sebaceous run from the
glands within the areola. sternum or
○ Increased firmness or umbilicus to the
tenderness of the breasts. symphysis pubis.
○ More prominent and visible
veins due to the increased blood C. Chloasma
supply. (Melasma)
○ Presence of colostrum (the - This is called the
thin yellowish fluid that is the "mask of
precursor of breast milk). pregnancy".
- It is seen after the 16th
week of pregnancy.
5. Vaginal Changes
Leukorrhea
- This is an increase in the
white or slightly gray mucoid Probable Signs of Pregnancy
discharge that has a faint
musty odor. - Probable signs of pregnancy are
those signs commonly noted by
the physician upon examination from contamination by bacteria
of the patient. in the vagina.
- This includes the ff:
- Braxton-Hick's contractions
- involves painless uterine
1. Uterine Changes contractions occurring
- By the twelfth week, the throughout pregnancy.
uterus rises above the
symphysis pubis and it - begins about the 12th week of
should reach the pregnancy and becomes
xiphoid process by the progressively stronger.
36th week of pregnancy
- Hegar's sign - Positive Pregnancy Test by
- Softening of the Physician
lower uterine - If the test is positive, it could be
segment just above the result of ectopic pregnancy or
the cervix. a hydatidiform mole
- Ballottement
● Ballottement is - Fetal outline Palpation
when the lower - Is a probable sign of early
uterine segment or pregnancy.
the cervix is tapped
by the examiner's
finger and left there,
the fetus floats Positive Sign of Pregnancy
upward, then sinks
back and a gentle - Positive signs of pregnancy are
tap is felt on the those signs that are definitely
Finger. confirmed as pregnancy.
2. Cervical Changes a. Fetal Heart Sounds
- Goodell's sign • 5 weeks
Is when there is a ○ Echocardiography can demonstrate a
heartbeat.
marked softening • 6th to 7th week
of the cervix ○ An ultrasound can reveal a beating
- present at 6 fetal heart.
weeks of • 10th to 12th week of gestation
○ Able to detect fetal heart sounds thru
pregnancy. doppler.
- Formation of a Mucous Plug • 18th to 20th week of pregnancy
(Operculum) ○ Fetal heartbeat can be heard through
- Due to hyperplasia of the an ordinary stethoscope.
cervical glands as a result of ○ The normal fetal heart rate is 120 to
160 beats.
increased hormones.
b. Ultrasound Scanning of the Fetus.
- serves to seal the cervix of the • The gestation sac can be seen and
pregnant uterus and to protect it photographed.
• An embryo as early as the 4th week seal out bacteria and help
after conception can be identified. prevent infection in the
• The fetal parts begin to appear by
the 10th week of gestation. fetus and membranes.
c. Palpation of the Entire Fetus
- a positive sign after the 24th 3. Vaginal Changes
week of pregnancy if the woman - Chadwick's Sign
is not obese - The resulting increase in
circulation (due to estrogen)
d. Palpation of Fetal Movement. changes the color of the vaginal
- is done by a trained examiner. It walls from their normal light pink
is easily elicited at the 20th - 24th to deep violet.
week of pregnancy.
- Leukorrhea
Categorization of Physiologic
- Increase in the activity of the
Changes:
epithelial cells.
1. Local changes
2. Systemic Changes
- Change of Vaginal pH
- Fall from pH greater than 7 (an
Local Changes
alkaline pH) to 4 or 5 (acid pH)
- Under the influence of
estrogen, the vaginal epithelium
1. Uterine Changes
● Length grows from approximately and underlying tissues increase
6.5 to 32 cm. in size as they become enriched
● Depth increases from 2.5 to 22 with glycogen where
cm. Lactobacillus acidophilus
● Width expands from 4 to 24 cm.
● Weight increases from 50 to 1000 (Doderlein bacillus) grow freely
grams. and produce lactic acid.
● Early pregnancy - uterine wall
thickens from 1 cm to 2 cm. 4. Ovarian Changes
● End of pregnancy - the wall thins - Cessation of Ovulation
to become supple and only about 0.5
cm thick.
5. Changes in the Breasts
2. Cervical Changes
Systematic Changes
- Goodell's sign
- Softening of the cervix
- The cervix of the uterus A. Integumentary System
becomes more vascular and • Striae gravidarum
edematous than usual causing
• Diastasis
it to soften n consistently (due
- Rectus muscles separate
to estrogen).
- Abdominal wall is
unable to withstand the
- Operculum
tension created by the
-A mucus plug forms to
enlarging uterus.
• Linea nigra additional 400 mg of
- Brown line form umbilicus to iron. - Total requirement
the symphysis pubis for iron = 800 mg
• Melasma - "mask of pregnancy" - Lack of folic acid has
- Due to melanocyte-stimulating been linked to an increased
hormone risk for neural tube disorder
• Vascular spiders in fetuses. - Foods high in
- Due to an increase in folic acid: Spinach,
estrogen. Asparagus, Legume
• Peripheral blood flow
- During the 3rd tri, blood flow
B. Respiratory System to lower extremities is
• Congestion or "Stuffiness" of the impaired due to pressure of
nasopharynx. gravid uterus to veins and
- Due to increased estrogen arteries.
levels. - Can lead to edema and
• Dyspnea (end of 3rd trimester) varicosities of the vulva, rectum,
- - Enlarging the uterus places legs.
pressure upward toward the lungs • Supine Hypotension Syndrome
and elevates the diaphragm. - Weight of the growing
• Mild hyperventilation uterus presses the vena
- To blow off excess CO2 being cava against the
shifted to her by the fetus vertebrae obstructing the
• Temperature blood flow from the lower
- Slight increase due to extremities.
progesterone. - This causes a decrease in
the blood return to the
heart, and consequently,
decreased cardiac output
C. Cardiovascular System and hypotension
• Increase in blood volume (lightheadedness, faintness,
- To provide for an adequate palpitation)
exchange of nutrients in the - Can result in fetal hypoxia.
placenta. • Increased fibrinogen (necessary for
• Pseudoanemia clotting)
- Plasma volume increases - Due to increased estrogen
faster than RBC, the - Safeguard against major
concentration of bleeding.
hemoglobin and Pre-pregnancy - 300 mg/dL
erythrocytes may decline. - Pregnancy - 450 g/dL
• Iron, Folic acid, Vitamin needs • Increased WBC
- Fetus requires 350 - 400 mg of - Protective mechanism
iron to grow - Reflection of the woman's
- Increase in the increased blood volume
mother's circulatory RBC • Protein level decreased
mass requires an - Indicating the amount of
protein used by the fetus. they brush their teeth.
D. Gastrointestinal System E. Urinary System
• Heartburn (pyrosis) - There is an increased
- Due to: response of the angiotensin-
▪ Reflux of stomach renin system in the kidney,
contents into the leading to increase
esophagus and a aldosterone production.
relaxed cardio
esophageal G. Endocrine System
sphincter caused by • Placenta
the action of relaxin - Estrogen
and progesterone. ▪ Causes breast & uterine
• Flatulence, Constipation enlargement
- Slow emptying time of the ▪ Causes palmar erythema
stomach, slow intestinal - Progesterone
peristalsis ▪ Maintains endometrium
- Due to relaxin and ▪ Inhibits uterine
progesterone. contractility
• Nausea and vomiting ▪ Aids in the development
- Due to: of the breasts for lactation
▪ Increased hCG, estrogen - hCG
and progesterone levels ▪ Secreted by the
▪ Decreased glucose trophoblast cells of the
levels (glucose being placenta in early
used by the growing pregnancy.
fetus) = FBS 95 mg/dL - hPL
or lower. ▪ Antagonist to
• Hyperptyalism insulin which
- Increased in saliva formation allows more
- A local response to increased glucose to
levels of estrogen. become available
• Subclinical Jaundice for fetal growth.
- Due to decreased - Relaxin
emptying of bile from the ▪ Secreted primarily by
gallbladder that leads to corpus luteum
reabsorption of bilirubin ▪ Inhibit uterine activity
into the maternal
bloodstream causing Prostaglandins
generalized itching. ▪ Affect smooth muscle
- Increased tendency to stone contractility
formation due to additional ▪ They may be the trigger
cholesterol incorporated in bile. • that initiates labor at term.
Hypertrophy of gumlines and - Pituitary Gland
bleeding of gingival tissue when
▪ Increase production of ▪ Glucose level of fetus is
GH & MSH 30 mg/100 ml
▪ Oxytocin is produced ▪ Pregnant woman
by post. Pituitary should keep her diet
gland late in high in calories and
pregnancy is should never go
needed to aid in longer than 12 hrs.
labor. between meals.
▪ Prolactin begun late in ▪ In early pregnancy, FBS
pregnancy to prepare for is 80 - 85 mg/100 ml.
lactation.
- Thyroid & Parathyroid
▪ Thyroid gland enlarges H. Immune System
early in pregnancy • Immunoglobulin G (IgG) is
causing increased decreased making the
basal body metabolic woman more prone to
rate by 20%. infection during pregnancy.
▪ Parathyroid glands are • IgG comprises 80% of the
necessary for calcium antibodies in adults (main type of
metabolism. antibody).
- Adrenal Glands
▪ Increase levels of
corticosteroids and
aldosterone
▪ Aids in suppressing an
inflammatory reaction
▪ Help reduce the
possibility of a woman's
body rejecting the fetus.
▪ Help regulate glucose
metabolism.
▪ Increase
aldosterone aids
in promoting
sodium
reabsorption and
maintaining
osmolarity in the
amount of fluid
retained.
- Pancreas
▪ Increase production of
insulin in response to
higher levels of
glucocorticoid produced
by the adrenal glands.