Assessment of Maternal Well Being

First Prenatal Visit

- -occurs as soon as the woman thinks she is pregnant

- the longest visit because this is when baseline data are collected

Objectives

- to confirm or rule out pregnancy

- to ascertain risk factors
- to determine due date
- to provide education on maintaining a healthy pregnancy

Components

1. History
- Most important element
- Written questionnaire or face to face interview

Parts of History Taking

a) Chief Complaint (Amenorrhea)

b) Reproductive (LMP, GPTAL Gravida, Para, Term, Abortion, Live, Menarche, Duration of the
Menses)
c) Medical/Surgical
d) Family History
e) Social History (Social Status, Occupation)
2. Physical Examinations
- Covers all body systems
- Head to toe exam
- Vaginal speculum exam (Papanicolaou Test/Pap Smear)
3. Laboratory Assessment
- CBC (to detect anemia and levels of Hemoglobin)
- Blood type and antibody screen
- Rubella titer
- Urine Culture
- TB Screening (PPD - Purified Protein Derivative)
- Ultrasound

Subsequent Visits

Schedule Week No. of Visit

1-32 Once a month
32-36 2 times a month
36 to delivery Every week

Include Specific Assessments

 Weight (1st trimester 3 pounds, 2nd trimester 12 pounds, 3rd trimester -12 pounds)
Blood Pressure (BP)
Urine protein and glucose
Fetal Heart Rate
Danger Signs of Pregnancy
Fetal Movement
Contractions
Bleeding
Member Rupture
Fundal Height

Danger Signs of Pregnancy

- Fever or severe vomiting ( PIH)

- Sever or continuous headache (PIH)
- Blurred vision or spots before the eyes
- Pain in the epigastric or abdominal areas
- Sudden weight gain or sudden onset of edema
- Vaginal bleeding
- Painful urination (UTI)
- Sudden gush or constant uncontrollable leaking of fluid from the vagina (PROM)
- Decrease fetal movement

Signs of Preterm (<37wks) Labor

- Uterine contractions
- Labor is a series of event such as the uterine contractions that ends with the expulsion of the products of
conception
- Painful and regular contraction
- Lower, dull backache (as a result of crowning or engagement)
- Pelvic pressure
- Menstrual like cramps
- Increase vaginal discharge
- A feeling something is not right

Markers in Fetal Development

4 Weeks (1 Months)

- Embryo is 4-5mm
- Trophoblast is embedded in the decidua
- Foundations for Nervous System, Genitourinary System, Skin, Bones, and Lungs are formed
- Rudiments of eyes, ears and nose appear

5-8 Weeks

- Fetus is 27-31mm and 2-4 g

- Fetus is markedly bent
- Head is disproportionately large as a result of brain development (brain matures up to 7 y/o)
- Sex differentiation begins
 - Centers of bone development begin to ossify

9-12 Weeks

- Fetus is 50-87mm and 45 g

- Fingers and toes are distinct
- Placenta is complete
- Rudimentary kidneys begin to secrete urine
- Fetal circulation is complete
- External genitalia shows definite characteristics

13-16 Weeks

- Fetus is 94-140mm and 97 200 g

- Head is erect
- Lower limbs are well developed
- Coordinated limb movements are present
- Heartbeat is present
- Lanugo develops (for temperature regulation)
- Nasal septum and palate closes
- Fingerprints are set

17-20 Weeks

- Fetus is 150-190mm and 260-460 g

- Lanugo covers entire body
- Eyebrows and scalp hair is present
- Heart sounds are audible via auscultation
- Vernix caseosa covers skin
- Wrinkling of skin means absence of subcutaneous tissue

21-25 Weeks

- Fetus is 200-240mm and 495-910 g

- Skin appears wrinkled and pink to red
- REM begins
- Eyebrows and fingernails develop
- Sustained weight gain occurs

26-29 Weeks

- Fetus is 250-275mm and 910-1500 g

- Skin is red
- Rhythmic breathing occurs
- Pupillary membrane disappears from eyes
- Fetus often survives if born prematurely

30-34 Weeks

- 280-320mm and 1700-2500 g

- Toenails become visible
- Steady weight gain occurs
 - Vigorous fetal movement occurs

35-37 Weeks

- 330-260mm and 2700-3400 g

- Face and body have loose and wrinkles appearance because of subcutaneous fat deposit
- Body is usually plump
- Lanugo disappears
- Nails reach fingertip edge
- Amniotic Fluid decreases

38-40 Weeks

- 360mm and 3400-3600 g

- Skin is smooth
- Chest is prominent
- Eyes are uniformly slate colored
- Bones of the skull are ossified and nearby together at the sutures
- Testes are in scrotum

Cryptorchidism failure of the testes to descent to the scrotum

Common Discomforts During Pregnancy

Relieving the Common Discomforts

1. Ankle Edema
- Rest with feet elevated
- Avoid standing for long periods of time
- Avoid restrictive garments on the lower half of your body
2. Backache
- Apply local heat
- Avoid long periods of standing
- Stoop to pick up objects
- Tylenol in usual adult dose may help
- Wear low heeled shoes
- Maintain correct posture
- Tailor sitting, pelvic rocking, and shoulder circling exercises strengthen back
3. Breast tenderness
- Wear a supportive bra
- Decrease the amount of caffeine and carbonated beverages ingested
4. Constipation
- High fiber diet
- Drink additional fluids
- Regular time for bowel movements
5. Difficulty Sleeping (as a result of positioning)
- Drink a warm, caffeine free drink before bed and practice relaxation techniques
6. Fatigue
- Schedule rest periods daily, have regular bedtime routine
- Use extra pillow as needed
7. Faintness
- Move slowly
- Avoid crowds
- Remain in a cool environment
- Lie on your left side
8. Headache
- Avoid eye strain
- Visit eye doctor
- Rest with cool cloth in your forehead
- Take Tylenol in a regular adult dose PRN
- Report frequent and persistent headache to your primary care provider
9. Heartburn (Pyrosis)
- Avoid overeating, as well as spicy, fatty and fried foods
10. Hemorrhoids
- Avoid constipation and straining with a bowel movement
- Take a sitz bath. Apply a hazel compress
11. Leg cramps
- Avoid pointing toes
- Straighten legs and dorsiflex ankle
12. Nausea
- Eat 6 small meals /day rather than 3
- Eat a piece of dry toast or some crackers before getting out of bed
- Avoid food/situations that worsen the nausea. If it persists, report the problem to your primary care
provider
- Drink fluids separately rather that with your meals
- Avoid fried, greasy, gas producing, or spicy foods with strong odors
13. Nasal Stuffiness
- Use of cool air vaporizer, humidifier, increase fluid intake, place moist towel on the sinuses and massage
the sinuses

14. Ptyalism
- Use mouth wash PRN
- Chew gum or suck on hard candy
15. Round ligament pain
- Avoid twisting motion
- Rise to a standing position slowly and use hands to support the abdomen
- Bend forward to relive discomfort
16. Shortness of breath
- Proper posture
- Us e pillows behind head and shoulders at night
17. Urinary frequency
- Void as necessary every 2 hours
- Increase fluid intake
- Avoid caffeine
- Practice Kegel exercises
18. Vaginal discharges
- Wear cotton underwear
- Bathe daily
- Avoid tight pantyhose
19. Varicose veins
- Walk regularly. Rest with feet elevated
 - Avoid long period of standing and sitting
- Dont cross legs while sitting
- Avoid knee high stocking. Wear support hosiery

Teaching Self Care During Pregnancy

1. Maintain a balanced nutritional intake

- Green leafy vegetables is a source of folate
- Additional of 500kCal a day
2. Bathing
- Daily tub baths and shower are recommended
- As pregnancy advances, change tub bath to sponge bath
- If vaginal bleeding /rupture of membrane are present , tub bath is contraindicated
3. Breast care
- Firm and supportive bra with wide straps
- Wash breast with clear tap water (no soap) daily to remove colostrum
- If colostrum secretion is profuse, place gauze or breast pads inside the bra
4. Dental care
- Good tooth brushing habits should continue throughout pregnancy
- Encourage pregnant women to see her dentist regularly
- Encourage snacking of nutritious food
5. Perineal Hygiene
- Douching is contraindicated
- Leukorrhea
- Wash perineal area regular with mild soap and water
6. Dressing
- Avoid garters, extremely firm girdles with panty legs and knee high stockings
- Girdles should be worn after pregnancy
- Shoes should be moderately high or flat
7. Sexual ability
*Common myths
- coitus on the expected date will initiate labor
- orgasm will initiate labor
- coitus during fertile days of a cycle will cause a second pregnancy of twins
- Coitus might cause rupture of membrane
8. Exercise
- To prevent circulatory stasis on the lower extremities
- It can also offer a general feeling of well being
- Exercise program should consists of :
*5 min warm up
*20 min stimulus phase
*5 min cool down
9. Sleep
- Needs an increase amount of sleep to build new body cells during pregnancy
- Drinking a warm milk may help and relaxation exercise
- Sims Position with top leg forward
10. Travel
- Early in pregnancy, there is no restrictions
- When travelling, avoid eating uncooked food and drinking unpurified water
- If in a long trip, plan for a frequent stretch or rest period
Prevention of Fetal Exposure to Teratogens

Teratogen

- Any factor, chemical or physical that adversely affects the fertilized ovum, embryo or fetus

Factors that influence the effect of Teratogen to the Fetus

1. Strength of Teratogen
2. Timing of teratogenic insult
3. Teratogens affinity to specific tissue
E.g. Thalidomide causes limb defects
Tetracycline causes tooth enamel deficiency

1. Teratogenic Maternal Infections

- Either sexually transmitted or systemic infection
- TORCH Group of diseases
a) Toxoplasmosis
- A protozoan infection
- Uncooked meat, handling of cat stool in soil or cat litter
- Almost no symptoms
- For fetus: CNS damage, hydrocephalus, microcephaly, retinal deformities
b) Rubella
- Mother: causes mild rash and mild systemic illness
- Fetus: deafness, mental and motor challenges, cataracts, cardiac defects, retardation, cleft lip or
palate
c) Cytomegalovirus (CMV)
- Member of herpes virus family
- Droplet infection from person to person
- Fetus: severely neurologically challenged, eye damage, deafness, chronic liver disease
d) Herpes simplex virus (genital herpes infection)
- Virus spreads into the blood stream and crosses the placenta
- 1st trimester: severe congenital abnormalities or spontaneous miscarriage
- 2nd and 3rd trimester: premature birth or IUGR (Intrauterine Growth Retardation/Restriction
2. Medication Use
- General principle: almost all medications cross the placenta and can potentially affect the fetus
- No medication (OTC or herbal) should be used during pregnancy without the approvals of the primary
care provider
3. Substance use and abuse
1. Caffeine
- may be safe if taken in a moderation during pregnancy
- increases the risk of spontaneous abortion
2. Tobacco
- contraindicated
- Low Birth Weight (LBW), preterm labor, abortion, still births, SIDS, and neonatal respiratory disorders
3. Alcohol
- no safe amount of alcohol consumption during pregnancy
4. Marijuana
- Fetus: Stressed nervous system
5. Cocaine
- spontaneous abortion and premature labor
 - infants are small and have higher incidence of low birth weight
4. Environmental Teratogens
a) Metal and Chemical Hazards
- Pesticides and CO
- Arsenic (by product of copper and lead smelting)
- Paints
- Mercury
- Formaldehyde
b) Radiation
- X rays and photocopiers
c) Hyperthermia and Hypothermia

5. Teratogenicity of Maternal Stress

*Common Myths
a) If a women sees a mouse during pregnancy, her child will be born with a furry/mole like birth
mark
b) Eating strawberries causes strawberry birthmarks
c) Looking at a handicapped while pregnant will cause child on uterus to be handicapped in the same
way
- Common sense and awareness of fetal-maternal physiologically have dispelled these superstition

Child Birth Education

- Classes conducted to prepare expectant parents for childbirth
- Not synonymous to painless or drugless delivery
Common Topics
- Psychological and emotional aspects of pregnancy
- Induction of labor through the administration of Oxytocin
- Partners role in providing support
- Medication and anesthesia options
- What to pack for the hospital
- Hospital admission routine
- Caesarian birth

Specific Goals

1. Prepare expectant mother and her partner for the childbirth experience
2. Create clients who are acknowledgeable consumers of OB Care
3. Help client reduces and manage pain with both pharmacologic and non pharmacologic method
4. Help increase couples overall enjoyment and satisfaction of the childbirth experiences

Additional Notes
Abruptio placenta early separation of the placenta
Hemangioma - cluster of blood vessels: a benign tumor or birthmark consisting of a dense, often raised
cluster of blood vessels in the skin
Epidural anesthetic injected to the spine usually during child birth