Angeles University Foundation Angeles City College of Nursing SY 2010-1011

Written Report PRENATAL CARE

Submitted by: Mylene Angelie M. Bognot Aaron Josh D. Bondoc Carla Joy T. Manaloto Of BSN II- 5; Group 24

Submitted to: Hydee A. Medina, RN MN

September 23, 2010

INTRODUCTION Women are convinced by the media, their physicians, relatives, etc., that prenatal care means going to the doctor for regular checkups. Frequent examinations are required by physicians to check for sugar in the urine, blood count, edema, etc. These "complications" are considered by conventional standards to be normal and therefore need to be checked for. Instead of avoiding these complications by right living, these abnormalities are tested for throughout pregnancy. What women are not told is that all these tests (especially vaginal exams) are very weakening and should be avoided and, in fact, visits to physicians are not only needless but filled with many dangers for both mother and offspring. The medical establishment conducts many tests on pregnant women to discover trouble only after it is developed. They have no ways of guiding women to healththey deal with pathological effects, not causes. Normally, physicians utilize drugging, which adds to the harm, to "remedy" the "problems" they maintain to discover with their tests. Prenatal care, however, does not mean visiting your obstetrician at all. It means providing the healthful conditions so as to produce and maintain better health and development in the unborn child. In other words, the child is very much so "at the mercy of the mother" for all the requisites of development and growth and freedom from harmful toxins. Prenatal care includes wholesome outdoor exercise, pure air, rest and sleep, sunshine, freedom from worry or anxiety, absence of overwork, and most importantly, proper food. The unborn child is totally dependent upon the mother to provide these things prudently. Pregnant women need not eat more food than they did prior to pregnancy as is commonly asserted. They need only eat the best of foodsraw fruits, vegetables, nuts, and seeds. These foods will provide an abundance of minerals, vitamins, and high-grade proteins for both mother and baby. Good foods are the raw materials for better eyes, better bones, better teeth, a better nervous system, a better brain, and better development all around the baby. Proper foods also improve the health and comfort of the mother and allow, for greater ease in delivery and healthier nursing.

Good food is not enough, however. A pregnant woman must secure the best conditions for efficient utilization (assimilation) of her food. She must observe food combining rules, eat only when hungry, never overeat or eat when emotionally upset or physically tired, never drink with her meals, etc.

Terms: Prental care- The medical and nursing supervision and care given to the pregnant woman during the period between conception and the onset of labor Gravida- a woman who is or has been pregnant. Primigravida- a woman who is pregnant for the first time. Multigravida- a woman who has had two or more pregnancies. Nulligravida- a woman who has never been pregnant. Para- the number of pregnancies that reached viability, regardless of wheter the infants were born alive or not Primipara- a woman who has giv en birth to a child past age of viability. Multipara- a woman who has given birth to two or more children past the age of viability. Viability- the earliest age at which fetuses could survive if they were born at that time; generally accepted at 24 weeks or weighing more than 400g. Tpal- a system for classifying pregnancy status attempts to further detail pregnancy history. T: The number of full term infants born (infants born at 37 weeks or after). P: The number of preterm infants born (infants born before 37 weeks). A: The number of spontaneous or induced abortions. L: The number of living children. Porturient a woman in labor

Puerpera (a woman who has just delivered (win 6 weeks after delivery )

Skillbirth (an infant born without signs of life)

Prenetal care (antenatal care) - refers to the health care given to a woman and her family during pregnancy essential for ensuring the overall health of newborn and mothers a major strategy for helping reduce complications of pregnancy. If a woman has a good health coming into pregnancy, it will help ensure a good pregnancy outcome Purposes of Prenatal Care: Establish baseline of present health Determine gestational age of the fetus Monitor fetal development and maternal well-being Identify women at risk for complication Minimize the risk for possible complication by anticipating and preventing problems before they occur Providing time for education about pregnancy, lactation and newborn care

ADAPTATIONS IN PREGNANCY A. Systemic Changes 1. Circulatory/Cardiovascular *Beginning the end of the first trimester there is a gradual increase of about 30%-50% in the total cardiac volume, reaching its peak during the 6 th month. This cause a drop in hemoglobin and hematocrit values since the increase is only in the plasma volume = physiologic anemia of pregnancy. Consequences of increased total cardiac volume are: Easy fatigability and shortness of breath because of increased workload of the heart. Slight hypertrophy of the heart, causing it to be displaced to the left, resulting in torsion on the great vessels ( the aorta and pulmonary artery ).

 Systolic murmurs are common due to lowered blood viscosity. Nosebleeds may occur because of marked congestion of the nasopharynx as pregnancy progresses. *Palpitations are due to: Sympathetic nervous system stimulation during the first half of pregnancy. Increased pressure of uterus against the diaphragm during second half of pregnancy. *Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities: Edema of the lower extremities occurs. Management: raise legs above hip level. Important : Edema of the lower extremities is normal during pregnancy; it is not a sign of toxemia. Varocosities of the lower extremities can also occur. Management: > Use/wear support hose or elastic stockings to promote venous flow > Apply elastic bandage start at the distal end of the extremity and work toward the trunk to avoid congestion and impaired circulation in the distal part; do not wrap topes so as to be able to determine adequacy of circulation ( principle behind bandaging : blood flow through tissues is decreased by applying excessive pressure on blood vessels ). > Avoid use of constricting garters, e.g., knee-high socks. *Because of poor circulation in the blood vessels of the genitalia due to the pressure of the gravid uterus, varicosities of the vulva and rectum can occur. Management: side-lying position with hips elevated on pillows and modified knee-chest position.

*There is increased level of circulating fibrinogen, that is why pregnant women are normally safeguard against undue bleeding. However, this alson predisposes them ton formation of blood clots (thrombi). The implication is that pregnant women should not be massaged since blood clots can be released and cause thromboembolism. 2. Gastrointestinal changes * Morning sickness nausea and vomiting during the first trimester is due to increased human chorionic gonadotropin (HCG). It may also be due to increased acidity or even to emotional factors. Management: Eat dry toast or crackers 30 minutes before arising in the morning (or dry, high carbohydrate, low fat and low spices in the diet). * Hyperemesis gravidarum = excessive nausea and vomiting which persist beyond 3 months; results in dehydration, starvation and acidosis. Management: D10NSS 3000 ml in 24 hours is the priority treatment; complete bed rest is also important. * Constipation and flatulence are due to displacement of the stomach and intestines, thus slowing peristalsis and gastric emptying time. It may also be due to increased progesterone during pregnancy. *Management: Increased fluids and roughage in the diet established regular elimination time Increased exercise Avoid enemas Avoid harsh laxatives like Dulcolax; stool softeners, e.g., Colace, are better. Mineral oil should not be taken because it interferes with absorption of fat-soluble vitamins.

* Hemorrhoids are due to pressure of enlarged uterus. Management: cold compress with witch hazel or Epsom salts * Heartburn, especially during the last trimester, is due to increased progesterone which decreases gastric motility, thereby causing reversed peristaltic waves which lead to regurgitation of stomach contents through the cardiac sphincter into the esophagus , causing irritation. Management: Pats of butter before meals Avoid fried, fatty foods Sips of milk at frequent intervals Small, frequent meals taken slowly Bend at the knees, not at the waist Take antacids (e.g., milk of Magnesia) but never sodium bicarbonate (e.g., Alka Seltzer or baking soda) because it promotes fluid retention. 3. Respiratory changes - shortness of breath *Causes Increased oxygen consumption and production of carbon dioxide during the first trimester. Increased uterine size causes diaphragm to be pushed or displaced, thus crowding the chest cavity. Management: Lateral expansion of the chest to compensate for shortness of breath oxygen supply and vital lung capacity. 4. Urinary changes *Urinary frequency, the only sign in pregnancy seen during the first trimester, disappears during the second and reappears during the third trimester. Early pregnancy is due to increase blood supply to the kidneys and to the

uterus rising out of the pelvic capacity; in the last trimester is due to pressure of enlarged uterus on the bladder, especially with lightening (descent of the fetus into the pelvic brim.) *Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; also an effect of the increased progesterone. (Implication: it would be difficult to diagnose diabetes in pregnancy based on the urine sample alone because all pregnant women have sugar in their urine.) 5. Musculoskeletal changes *Because of the pregnant womans attempt to change her center of gravity, she makes ambulation easier by standing more straight and taller, resulting in a lordotic position (pride of pregnancy) *Due to increased production of the hormone relaxin, pelvic bones become more supple and movable, increasing the incidence of accidental falls due to the wobbly gait. Implication: Advice use of low-heeled shoes after the first trimester. *Leg cramps *Causes Increased pressure of gravid uterus on lower extremities Fatigue Chills Muscle tenseness Low calcium, high phosphorus intake

6. Temperature - slight increase in basal body temperature due to increases progesterone,but the body adapts after 4th month.

7. Endocrine changes *Addition of the placenta as an endocrine organ, producing large amounts of HCG, HPL, estrogen and progesterone. *Moderate enlargement of the thyroid gland due to hyperplasia of the glandular tissues and increased vascularity. It could also be due to increased basal metabolic rate to as much as +25% because of the metabolic activity of the products of conception. *Increased size and activity of the parathyroid, probably to satisfy the increases need of the fetus for calcium. *Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortisol, aldosterone and ADH, all of which affect carbohydrate and fat metabolism, causing hyperglycemia.

*Gradual increase in insulin production but the bodys sensitivity to insulin is decreased during pregnancy. 8. Weight *During the first trimester, weight gain of 1.5-3 lbs is normal *On the 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is recommended. *Total allowable weight gain during entire period of pregnancy, therefore, is 20-25 pounds (10-12 kgs).

Fetus Placenta Amniotic Fluid

7 lbs. 1 lb. 1 lbs

Increased weight of uterus Increased blood volume Increased weight of the breasts Fat and fluid accumulation characteristic of pregnancy TOTAL:

2 lbs. 1 lb. -3 lbs. 4 lbs.

20-25 lbs.

*Pattern of weight gain is more important than the amount of weight gained. Distribution of Weight Gain during Pregnancy 9. Emotional responses *First trimester: The fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, disbelief, even depression. (Implication: when giving health teachings, emphasize bodily changes in pregnancy.) *Second trimester: fetus is perceived as a separate entity. It fantasizes appearance of the baby. *Third trimester: her personal identification with a real a baby about to be born and realistic plans for future childcare responsibilities. Best time to talk about layette and infant feeding method. Fear of death, though, is prominent. (to allay fears, let pregnant woman listen to the fetal heart sounds.)

B. Local changes 1. Uterus *Weight increases to about 1000 grams at full term; due to increase in the amount of fibrous and elastic tissues.

*Change in shape from pear-like to avoid; enormous change in consistency of lower uterine segment causes extreme softening, known as Hegars sign, seen at about the 6th week. *Mucous plugs in the cervix, called operculum, are produced to seal out bacteria *Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known as Goodells sign. 2. Vagina *Increased vascularity causes change in color from light pink to deep purple or violet known as Chadwicks sign * To prevent confusion as to pregnancy signs, arrange the body from out to in and the different signs alphabetically. Thus: Due to increased estrogen, activity of the ephitelial cell increases. Thus increasing amount of vaginal discharges called leucorrhea. As long as the discharges are not excessive, green/yellow in color, foulsmelling or irritatingly itchy, it is normal. Management: maintain or increase cleanliness by taking twice daily shower baths using cool water. The pH of the vagina changes from normally acidic (because of the presence of Doderlein bacilli) to alkaline (because of increased estrogen). Alkaline vaginal environment is supposed to protect against bacterial infection; however, there are two microorganisms which thrive in an alkaline environment. Trichomonas, a protozoa or flagellate. The condition is called trichomonas vaginalis or trichomonas vaginitis or trichomoniasis. Signs and Symptoms of Trichomoniasis >Frothy, cream-colored, irritatingly itchy, foul-smelling discharges. >Vulvar edema and hyperemia due to irritation from the discharges parts

*Management

Flagyl for 10 days p.o. or vaginal suppositories of trichomonicidal compounds. Treat male partner also with Flagyl Avoid alcoholic drinks when taking Flagyl can cause Antabuse like reactions: vomiting, flushed face and abdominal cramps. Dark brown urine a minor side effects Acidic vaginal douche ( tbsp. White vinegar in 1 quart of water or 15 ml. white vinegar n 1000 ml. of

water) to counteract alkaline- preferred environment of the protozoa. Avoid intercourse to prevent reinfection. Candida Albicans, a fungus or yeast. The condition is called Moniliasis or Candidiasis. Fungus also thrives in an environment rich in carbohydrates and in those on steroid or antibiotic therapy when acidic environment is altered. Moniliasis is seen as oral thrush in the newborn when transmitted during delivery through the birth canal of the infected mother. Symptoms White, patchy, cheese-like particles that adhere to vaginal walls Irritatingly itchy and foul-smelling vaginal discharges

Management Mycostatin/nystatin p.o. or vaginal suppositories/ pessaries( 100,000 U) twice a day for 15 days Gentian violet swab to vagina Correct diabetes Avoid intercourse Acidic vaginal douche

3. Abdominal Wall *Striae Gravidarum- increased uterine size results in rupture and atrophy of connective tissue layers, seen as pink or reddish streaks *Umbilicus pushed out 4. Skin *Linea nigra- Brown line running from umbilicus to symphysis pubis *Melasma or Chloasma- extara pigmentation on cheeks and across the mose due to increase of production of melanocytes by the pituitary gland *Sweat glands unduly activated 5. Breasts - all changes due to increased estrogen * Increased in size due to hyperplasia of mammary alveoli and fat deposits. Proper breast support with well-fitting brassiere necessary to prevent sagging. * Feeling of fullness and tingling sensation in the breasts * Nipples more erect. * Montgomery glands become bigger and more protuberant * Areola becomes darker and diameter increases * Skin rounding areola turns dark * By the fourth month, a thin, high protein fluid called Colostrum, Is formed. It is the precursor of breast milk. 6. Ovaries - no activity since ovulation does not take place during pregnancy. progesterone and estrogen are being produced by the placenta. Stage First trimester Presumptive Amenorrhea Morning sickness Breasts changes Urinary frequency Second trimester Enlarging uterus Quickening Probable Chadwicks sign Goodells sign Hegars sign Positive HCG Elevation of BBT Enlarged abdomen Fetal heart rate Positive Ultrasound evidence

Increase pigmentation

skin Braxton hicks Ballottement

tones Fetal movement felt by examiner Fetal online on Xray

(chloasma & linea nigra) Striae Gravidarum

C. The Prenatal Visit a. The provision of prenatal care is the primary factor in the improvement of maternal and infant morbidity and mortality statistics. To ensure the success of the prenatal care programs, it should be remembered that the patients understanding of the modalities of care is basic for cooperative action.

b. The duration of a normal pregnancy is 266-280 day, or 380-42 weeksor 9

calendar months or 10 lunar months. Any baby born after 42nd week of gestation is said to be post-term

c. Diagnosis of pregnancy. Urine examination- Human Chorionic Gonadotropin

(HCG) in the urine is the basis for pregnancy tests. It is from the 40th day through the 100th day, reaching a peak level on the 60th day. HCG therefore, is the most correct 6 weeks after the last menstrual period (LMP). Immunodiagnostic tests (antigen-antibody reaction) are widely used at present because results pobtain faster. d. Components of the prenatal visits 1. History taking *Personal data- patients name, age, address, civil status, and family history *Obstetrical data Gravida- number of pregnancies a woman has had Para- number of viable of pregnancies, regardless of number and outcome TPAL- number of full term babies (T), premature (P) babies, abortion (A), living children (L)

Past Pregnancies

>Method of delivery normal spontaneous vaginal, or caesarian section >Where? at home? in the hospital? >Risks involved Present pregnancy >Chief concern >Danger signals. >Vaginal bleeding, swelling of ace or finger, severe, continuous headache, dimness or blurring of vision >Pain in the abdomen >Persistent vomiting >Chills and fever >Sudden escape of fluids from the vagina >Absence of fetal heart rate they have been initially auscultated on the 4th or 5th month *Medical data- is there a history of kidney, cardiac or liver disease; hypertension; tuberculosis; sexually- transmitted diseases 2. Assessment *Physical examination- a review of system is indicated. *Pelvis examination *Internal examination to determine hegars Chadwick and goodells *Ballottement- fetus will bounce when lower uterine segment is tapped sharply *Papanicolau(pap smear)- cytological examination to diagnose cervical cancinoma *Leopolds maneuvers Purpose To determine presentation, position, and attitude Estimate fetal size Locate fetal parts Palpate with warm hands Use palm not fingertips

Preparatory steps

Apply gentle but firm motion

Procedure First Maneuver (Upper pole) o o o Examiner faces woman's head Palpate uterine fundus Determine what fetal part is at uterine fundus

Second Maneuver (Sides of maternal abdomen) o o o o Examiner faces woman's head Palpate with one hand on each side of abdomen Palpate fetus between two hands Assess which side is spine and which extremities

Third Maneuver (Lower pole) o o o o Examiner faces woman's feet Palpate just above symphysis pubis Palpate fetal presenting part between two hands Assess for Fetal Descent

Fourth Maneuver (Presenting part evaluation) o o o o Examiner faces woman's head Apply downward pressure on uterine fundus Hold presenting part between index finger and thumb Assess for cephalic versus Breech Presentation

Vital Signs- temperature, pulse and respiratory rates are important especially during the initial prenatal visit. more important, however, are the weight and blood pressure as baseline data to determine any significant increases. Blood studies Blood typing Complete blood count, including HGB, HCT, to determine anemia Serological test to diagnose for syphilis

Urine examinations Heat and acetic test to determine albuminuria. An sign of albumin in the urine should be reported immediately because it is a sign of toxemia Benedicts test for gycosuria, a sign of possible gestational diabetes. Urine shouldbe collected before breakfast to avoid false positive result. Should not be more the +1 sugar. Betermination of pyuria. Urinary tract infection has been found to be a common cause of premature delivery. Important Estimates Age of Gestation (AOG) Nageles Rule calculation of expected date of confinement (EDC). Count back three months from the first day of the last menstrual period (LMP) the add 7 days. Substitute number for month for easy computation. E.G., LMP is September 6 September is the 9th month of the year 3 = 6(June) Add 7 days to 6 = 13 EDC June 13 Problems encountered with the use of LMP 1. Failure to record LMP 2. Menstrual cycle maybe irregular and variable 3. Pregnancy may follow immediately without menstruation in between gestation 4. Implantation bleeding may be mistaken as menstruation

MCDonalds method determine age of gestation by measuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months. E.g., fundic height of 16 cm. divided by 4 = 4 months AOG = 16 weeks AOG o Estimate fetal weight -using the fundic height ( Johnsons rule ) Formula : FH (cm)- n x K= fetal weight in gms Where:

N=12 if the fetal head is below the level of the ischial spine (engaged) = 11 if the presenting fetal part is above the level of the ischial spine =1 is added to n for patients over 200 lbs K= 155 (constant) o Fetal length: (Haases Rule) in cm long First 5 months of pregnancy= Square the number of the month of pregnancy From 6th months on multiply the number of the month by 5 Bartholomews Rule estimate AOG by the relative position of the uterus in the abdominal cavity (Figure 4). By the 3 rd lunar month, the fundus is palpable slightly above the symphysis pubis on the 5th lunar months, the fundus is at the level of the umbilicus on the 9th lunar month, the fundus is below the xiphoid process

Growth of the fundic height 12 weeks- level of symphysis pubis 16 weeks- halfway between symphysis pubis and umbilicus 20 weeks- level of umbilicus 24 weeks- two finger above umbilicus 28-30weeks- midway between umbilicus and xiphoid process 36 weeks- at the level of xiphoid process 40 weeks- two fingerbreadths below xiphoid, drops at 34 weeks kevek because of LIGHTENING

D. NUTRITION most important aspect Food sources: Protein-rich foods meat, fish, eggs, milk, poultry, cheese, beans, mongo Vitamin A eggs, carrots, squash, all green and leafy vegetables Vitamin D fish, liver, eggs, milk, (Caution: excess Vitamin D during pregnancy can lead to fetal cardiac problems) Vitamin E green leafy vegetables, fish Vitamin C tomatoes, guava, papaya Folic Acid especially needed to prevent megaloblastic anemia, abruption placenta and prematurity because, together with iron, folic acid is needed for hemoglobin formation. E.g. asparagus Vitamin B foods rich in protein Calcium/phosphorus milk, cheese Iron especially important during the last trimester when the pregnant woman is going to transfer her iron stores from herself to her fetus so that the baby has enough iron stores during the first three months of life when all he takes is milk (which is deficient in iron). It has a very low absorption rate: only 10% of iron intake can be absorbed by the body. Iron should be given after meals because it is irritating to the gastric mucosa. Foods rich in iron: liver and other internal organs, camote tops, kangkong, egg yolk, ampalaya, malunggay. Quantities of Food Necessary during Pregnancy Smoking causes vasoconstriction, leading to low birth weight babies and, therefore, is contraindicated during pregnancy. Drinking in moderation is not contraindicated but when excessive can cause transient respiratory depression in the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty calories.

Drugs dangerous to fetus especially during the first trimester when the placental barrier is still incomplete and the different body organs are developing. Are teratogenic (can cause congenital defects) and, therefore, contraindicated unless prescribed by the doctor. >Thalidomide causes Amelia or phocomelia(short or no extremities) >Steroids - can cause cleft palate and even abortion >Iodine contained in many over-the-counter cough suppressants, cause enlargement of the fetal thyroid gland, leading to tracheal compression and dyspnea at birth. >Vitamin K causes hemolysis and hyperbilirubinemia >Aspirin and phenobarbital cause bleeding disorders >Streptomycin and quinine cause damage to the 8th cranial nerve (nerve deafness) >Tetracycline causes staining of tooth enamel and inhibits growth of long bones (not given also to children below 8 yrs. for the same reasons) E. Sexual Activity Sexual desires continue throughout pregnancy, but levels change: >During the 1st trimester, there is a decrease in sexual desire because the woman is more preoccupied with the changes in her body. >During the 2nd trim., there is an improvement in sexual desire because the woman has adapted to the growing fetus. >During the 3rd trim., there is another decrease in sexual desire because the woman is afraid of hurting the fetus. Sex in moderation is permitted during pregnancy but not during the last 6 weeks since there is increased incidence of postpartum infection in women who engage in sex during the last 6 weeks. Counsel the couple to look for more comfortable positions. Definitely, the missionary (man-on-top) position is not available. Sex is contraindicated in the ffg. situations: >Spotting or bleeding >Ruptured BOW >Incompetent cervical os >Deeply-engaged presenting part

F. Employment As long as the job does not entail handling toxic substances, or lifting heavy objects, or excessive physical or emotional strain, there is no contraindication to working. Advise pregnant women to walk about every few hours of her work day during long periods of standing or sitting to promote circulation. G. Traveling No travel restrictions but postpone a trip during the last trimester. On long rides, 15-20 minute rest periods every 2-3 hours to walk about or empty the bladder is advisable. H. Exercises Chief aim: To strengthen the muscles used in labor and delivery. Should be individualized: accdg. To age, physical condition, customary amount of exercise (swimming or tennis not contraindicated unless done for the first time) and the stage of pregnancy. Recommended exercises include: >Squatting and Tailor Sitting to stretch and strengthen perineal muscles; increase circulation in the perineum; make pelvic joints more pliable. When standing from squatting position, raise buttocks first before raising the head to prevent postural hypotension. >Pelvic rock maintains good posture; relieves abdominal pressure and low backache, strengthens abdominal muscles following delivery. >Modified knee-chest position relieves pelvic pressure and cramps in the thighs or buttocks, relieves discomfort from hemorrhoids. >Shoulder circling strengthens muscles of the chest. >Walking - said to be the best exercise. >Kegel relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles.