Prenatal ( Health Center) Handouts

Lecture Notes on Prenatal Care / Health Teachings

Prepared By: Mark Fredderick R Abejo R.N, MAN

Clinical Instructor

1

PRENATAL CARE and

HEALTH TEACHINGS

Basic Concepts in Pregnancy Signs of Pregnancy:

Presumptive Signs

Amenorrhea – absence of menses

Nausea and Vomiting

Increased breast sensitivity and breast changes

Increased pigmentation

Constipation

Frequent urination

Quickening

Abdominal enlargement

Probable Signs

Uterine enlargement

Hegar’s Sign

Goodell’s Sign

Chadwick’s Sign

Ballottement

Braxton Hick’s contraction

Positive Pregnancy Test

Positive Signs

Fetal Heart Tone

X-ray or Ultrasound of fetus

Palpable fetal movements

Discomforts of Pregnancy

Changes Reason Health

Teachings

Nausea and

Vomiting

Increased

HCG Dry crackers

30 min. before

arising

Small,

frequent, low

fat meals

Liquids bet.

meals

Avoid anti-

emetics.

Heartburn

Increased

progesterone

which dec.

gastric

motility

causing

esophageal

reflux.

Pats of butter

before meals

Avoid fried ,

fatty foods

Sips of milk at

frequent

intervals.

Small,

frequent meals

taken slowly.

Bends at the

knees, not at

the waist

Take antacids

Constipation Due to

displacemen

t of the

stomach and

intestines;

iron

supplements

Increased

fluids and

roughage in the

diet.

Regular

elimination

time.

Increase

exercise

Avoid enemas,

harsh laxatives

and mineral oil.

Hemorrhoids Pressure of

growing

fetus,

Increase

venous

pressure

Warm sitz

bathing

High fiber diet

and increase

fluid.

Sit on soft

pillow

Urinary

Frequency

Increase

blood supply

to the

kidney/

Pressure of

enlarged

uterus in the

3rd

Tri

Sleep on the

side at night.

Limit fluid

intake during

evening

Bladder

training

Backache From

exaggerated

lumbo-

sacral

curving

during

pregnancy.

Back exercise

(pelvic rock)

Wear low-

heeled shoes.

Avoid heavy

lifting



Clinical Instructor

2

Leg Cramps Increase

pressure of

gravid fetus,

low calcium

Frequent rest

with feet

elevated

Regular

exercise like

walking

Increase milk

intake

Ankle Edema From

venous

stasis

Elevate legs at

least twice a

day.

Sleep on left

side

Varicose

Veins

From faulty

valves or

weakened

vessel walls

Elevate feet

when sitting.

Use support

hose

Apply elastic

bandage

Avoid use of

constricting

garters

Shortness of

breath

From

pressure on

diaphragm

Sleep with feet

elevated or on

regularly.

Nasal

stuffiness and

epistaxis

Elevated

Estrogen

levels

Direct pressure

to the nasal

area

Avoid blowing

of nose.

Fatigue Due to

hormonal

changes

Get regular

exercise

Sleep as much

as needed.

Avoid

stimulants.

Breast

Tenderness

Increase

estrogen and

progesterone

level

Wear well

fitted bra

Warm

compress

Increased

Vaginal

discharges

Due to

hyperplasia

of mucosa

and increase

mucus

production

Consult

physician if

infection is

suspected

Wash carefully

and keep it dry.

Presumptive Signs of Pregnancy



Clinical Instructor

3

Formula Used In Providing Estimates In

Pregnancy

A. To estimate the EDC

Given the Use Formula

Last Menstrual

Period (LMP)

Nagele’s Rule First day of

LMP – 3

months + 7

days

Date of

Quickening

Primi:

Q + 4 months

+ 20 days

Multi:

Q + 5 months

+ 4 days

B. To estimate the AOG


Fundic Height McDonald’s

rule

Height in cm

FH x 2/7 =

duration in

months

FH x 8/7 =

Duration in

weeks

Fundus Height at Various week

C. Estimated Fetal Weight


Rump-to-

crown length

in utero cm.

Standard

Formula

Rump-to-crown

length in utero cm.

x 100 = weight in

gm

Johnson’s

Ruler

FH (cm)

- 11 (if unengaged )

- 12 ( if engaged ) x

155

Measuring the Fundic Height



Clinical Instructor

4

PRENATAL VISIT Maternal Health Program of the DOH

is tasked to reduced the maternal mortality

ratio by three-quarters by 2015:

MMR of 112/100,000 live births in 2010

MMR of 80/100,000 live births in 2015

Strategic Thrusts for 2005-2010

Launch and implement the Basic Emergency

Obstetric Care or BEMOC. The BEMOC

strategy entails the establishment of facilities

that provide emergency care for every 125,000

population.

Improve the quality of prenatal and postnatal

care

Reduce women’s exposure to health risks

through the institutionalization of responsible

parenthood and provision of appropriate health

care package to all women of reproductive ages.

LGU’s, NGOs and other stakeholders must

advocate for health through resource generation

and allocation of health services for the mother

and the unborn.

Prenatal Clinic Visits

Schedule of first visit is as soon as the woman

missed her menstrual period and pregnancy is

suspected

First 32 weeks : once a month

32-36 weeks : twice a month

36-40 weeks : every week

Length of Pregnancy

267-280 days

38-42 weeks (ave.40 weeks)

9 calendar months

10 lunar months

3 trimester

First Trimester: Period of Organogenesis

Second Trimester: Most comfortable for mother

with continued fetal growth.

Third Trimester: Period of rapid fetal growth

bec. of rapid deposition of fats

iron and calcium.

High Risk Factors During Pregnancy

Life of woman and fetus has significantly

increased risk of disability or death.

Generally, these are:

- abnormal fetal position or presentation

- age 35 years or younger than age 15 years

- bleeding during pregnancy

- drug or alcohol dependent

- hydramnios

- hypertension of pregnancy

- infection of mother

- maternal illness

- past history of difficult delivery

- post cesarean birth

- potential for blood incompatibility

Medical History and current status:

- obstetrical history, current status

- Psychosocial risks, maternal behaviors and

adverse lifestyle.

- smoking

- caffeine: 3 or more cups of coffee

- alcohol: no safe dose

- drugs

- abuse and violence

- Psychological status

- working more than 10 hours, heavy lifting

- standing more than 4 hours.

Socio-demographic risks:

- low income

- lack of prenatal care

- height less than 145 cm ( 4’9”)

- parity more than 5

- marital status

- residence

- ethnicity

Environmental risks:

- infection

- radiation

- chemicals

- physical; extreme heat more than 38.9 c,

noise, vibration and atmospheric pressure,



Clinical Instructor

5

Components of a Prenatal Visits

Initial interview Health history

- Menstrual history: menarche, regularity,

frequency and duration of flow and last period.

- Obstetrical history; all pregnancy, outcome,

complication, contraceptives use, sexual history

Danger Signs of Pregnancy

- Vaginal Bleeding

- Swelling of the face or finger

- Severe headache

- Blurring of vision

- Flashes of lights

- Pain in the abdomen

- Persistent vomiting

- Chills and fever

- Sudden escape of fluids from the vagina

- absence of fetal heart tone

Demographic data

Chief concern

Family profile

History of past illnesses

History of family illness

Gynecologic history

Obstetric history

Review of systems

Support person’s role

TPAL T = Full Term Babies

P = Premature

A = Babies Abortion

L = Living Children

Physical Examination

Review of System

Pelvic Examination ( Cardinal Rule: EMPTY BLADDER )

Internal Exam (I.E) to determine:

Hegar’s Sign – softening of the uterus

Goodell’s Sign – softening of the cervix

Chadwick’s Sign – bluish discoloration of

vagina.

Ballotement – fetus will bounce when

lower uterine segment is tapped

sharply

( on the 5th

month )

Fetal Heart Rate Assessment - Doppler Ultrasound ( 10-12 weeks )

- Stethoscope ( 18-20 weeks )

Expected Rate: 120-160 bpm



Clinical Instructor

6

Pelvic Measurement are preferably done

after the 6th

lunar month.

Xray Pelvimetry is the most effective

method of diagnosing cephalopelvic

disproportion. But since Xrays are

teratogenic, the procedure can be done

only two weeks before EDC.

Types of Pelvis

Papanicolau ( Pap Smear) –

cytological examination to

diagnose cervical cancer.

Classification of Findings

Class 1 – absence of abnormal cells

Class 2 – abnormal cell but no evidence of

malignancy.

Class 3 – cytology suggestive of malignancy

Class 4 – cytology strongly suggestive of

malignancy

Class 5 – conclusive for malignancy

Clinical Stages of Cervical Cancer

Stage 1 - Cancer confined to the cervix

Stage 2 - CA extends beyond the cervix into

the vagina

Stage 3 - metastasis to the pelvic wall

Stage 4 - metastasis beyond pelvic wall into

the bladder and rectum.

A.

1 : Nulligravida cervix

2 : Cervix after childbirth

3 : “Stellate” cervix seen after mild

cervical tearing.

B

1 : Herpes II

2 : Chancre of syphilis

3 : Erosion or infection



Clinical Instructor

7

Leopold, Maneuvers – are a systematic

methods of observation and palpation to

determine fetal position, presentation, lie and

attitude which helps in predicting course of

labor

Preparatory Steps:

1. Palpate with warm hands.

2. Use palms, not fingertips.

3. Woman should lie in supine position with

knees flexed slightly.

4. Done with empty bladder.

Procedure:

1st Maneuver

to determine presenting part

facing the head part of the pregnant woman,

palpate for fetal part found in the fundus to

determine presentation.

( a hard, smooth, ballotable mass at the fundus

means fetus is breech presentation )

2nd

Maneuver

to determine fetal back

still facing the head part of the mother, palpate

side to locate the fetal back.

a feel smooth hard resistant surface is the back

part. ( best place to hear the FHT )

a number of angular nodulation are knees and

elbows.

3rd

Maneuver

to determine engagement and mobility of

presenting part.

still facing the head part of the mother, grasp

the lower portion of the abdomen just above the

symphysis pubis to find out degree of

engagement.

4th

Maneuver

to determine fetal attitude and descent.

Now facing the feet of the mother, press

fingers downward on both sides of the uterus

above the inguinal ligaments to determine

degree of flexion of fetal head.



Clinical Instructor

8

Benedict’s Test Test for glycosuria, a sign of possible

gestational diabetes.

Urine should be collected before breakfast

results:

Blue - no sugar

Green - +1 sugar

Yellow - +2 sugar

Orange - +3 sugar

Red - +4 sugar

Vital Signs During Pregnancy

Blood Pressure : limit increase is 10/15

mmHg systolic – diastolic above baseline BP.

Pulse : 60 -90 beats per min.

Respiration : 16 – 24 cycles per min.

Temperature : 36.2 – 37.6 C ( 97-100 F )

PRENATAL

HEALTH TEACHINGS

Nutritional Health During Pregnancy

Nutrition – most important aspect

Weight Gain

11.2 to 15.9 kg. ( 25 – 30 lb ) recommended as an average weight gain in

pregnancy.

2 – 4 lbs during 1st trimester

11 – 14 lbs during 2nd

trimester

8-11 lbs from the 3rd

trimester

Note:

Pattern of weight gain is more important

than amount of weight gain.

Women who need special attention:

Pregnant teenagers

Low pre-pregnant weight and obese

Low income women

Successive pregnancies

Vegetarians

Nutritional Assessment

- Food preferences and eating habits

- Cultural and religious influences

- Education and occupational level

Assessing Maternal Weight Gain

Computation of Caloric Equivalents

Carbohydrates X 4

Proteins X 4

Fats X 9



Clinical Instructor

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Clinical Instructor

10

Food Sources

Protein Meat, fish, eggs, milk, poultry,

cheese, beans, mongo

Vit. A Eggs, carrots, squash, all green

leafy vegetables

Vit. D Fish, liver, egg, milk, margarine

Note: excess vit.D may lead to

fetal cardiac problem

Vit. E Green leafy vegetables, fish, corn

Vit. C Tomatoes, guava, papaya, citrus

fruits

Folic Acid Asparagus, organ meat, green

leafy vegetables

Vit. B ( foods rich in protein )

Calcium and

Phosphorus

Milk, cheese, green leafy

vegetables, whole grains,

seafood, tofu

Iron Pork liver, lean meat, kamote

leaves, soybeans, seaweeds,

mongo

Iodine Iodized salt, seafood, milk, egg,

bread

Micronutrient Supplementation

Vitamin A Supplementation

Target Prep. Dose Duration Remarks

Pregnant

Women

10,000

IU

1

cap

2x a

week

Start from

the 4th

month of

pregnancy

until

delivery

Vit. A

should

not be

given to

woman

who

already

taking

vit. that

also

contain

Vit. A

Post

Partum

Women

200,000

IU

1

cap

One dose

only

within 4

weeks

after

delivery

Vit.A

(200K

IU)

should

not be to

pregnant

women.

Pregnat

women

with

night

blindness

10,000

IU

1

cap /

day

For 4

weeks

upon

diagnosis

Vit. A

should

not be

given to

woman

who

already

taking

vit. that

also

contain

Vit. A

Iron Supplementation

Target Prep. Dose /

Duration

Remarks

Pregnant

Women

Coated

Tab.

contains

60 mg

elemental

iron with

400 mg

folic acid

1 tab/day for

6 months or

180 days

during

pregnancy

period

OR

2 tab/day if

prenatal

consultation

are done

during the

2nd

/3rd

trimester

A dose of

800 mcg

folic acid

is still

safe to

pregnant

woman

Lactating

Women

Coated

Tab.

contains

60 mg

elemental

iron with

400 mg

folic acid

1 tab / day for

3 months or

90 days

Iodine Supplementation

Target Prep. Dose / Duration

Women

15-45

yrs.old

Iodized oil

capsule with

200 mg.

iodine

1 capsule for 1

year



Clinical Instructor

11

TeTox Routine Immunization of

Pregnant Women

Vaccine Minimum

Interval

Percent

Protected

Duration of

Protection

TeTox 1 As early as

possible

during

pregnancy

TeTox 2

Minimum

required

TeTox for

pregnant

mother

4 weeks

after

TeTox 1

80% infant will

be

protected

by neonatal

tetanus

3 years

protection

for the

mother

TeTox 3 6 months

after

TeTox 2

95 % infant will

be

protected

by neonatal

tetanus

5 years

protection

for the

mother

TeTox 4 1 year

after

TeTox 3

99 % infant will

be

protected

by neonatal

tetanus

10 years

protection

for the

mother

TeTox 5 1 year after

TeTox 4

99 % all infant

born to that

mother will

be

protected

lifetime

protection

for the

mother

Dont’s During Pregnancy

Smoking Causes vasoconstriction,

leading to low birth weight

babies

Drinking Alcohol When excess can cause

respiratory depression in

newborn and fetal

withdrawal syndrome.

Delayed fetal growth and

development

Drugs Drugs are dangerous

especially during 1st Tri.

Thalidomide Causes amelia or

phocomelia (short or no

extremities

Steriods Can cause cleft palate and

abortion

Cough

suppressant

Can cause enlargement of

fetal thyroid gland leading

to tracheal compression and

dyspnea at birth

Vit.K Cause hemolysis and

hyperbilirubinemia

Aspirin Causes bleeding disorder

Streptomycin Cause damage to the 8th

cranial nerve

Tetracycline Causes staining of the tooth

enamel and inhibits growth

of long bones

Cocaine Causes abruption placenta,

preterm labor and fetal

death

Amphetamines Can cause jitteriness and

poor feeding at birth

Marijuana Increase incidence of

respiratory infection

Narcotics Small gestational age,

increase rate of fetal distress,

meconium aspiration,

abnormal fetal liver and lung

tissue

Inhalants Cardiac irregularities,

severe respiratory

depression.



Clinical Instructor

12

Sexual Activity

Sexual desires continue throughout

pregnancy, but levels change:

During the First Trimester: there is a decrease

in sexual desire because the woman is more

preoccupied with the changes in her body.

During the Second Trimester: there is an

improvement in sexual desire because the

woman has adapted to the growing fetus.

During the Third Trimester: there is another

decrease in sexual desire because the woman is

afraid of hurting the fetus.

Note:

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.

Recommended Position

- side by side position

- woman on top

- entrance at the back (dog’s style )

- side on the back

Sex is CONTRAINDICATED

Spotting or bleeding

Ruptured BOW

Incompetent cervical OS

Deeply-engage presenting part

Placenta previa

History of spontaneous miscarriage

Employment

As long as the job does not entail handling

toxic substance or lifting heavy objects or

excessive physical and emotional strain, there is

no contraindication to work.

Advise pregnant women to walk about every

few hours of her work day during long periods

of standing or sitting to promote circulation.

Traveling

No travel restriction, but postpone a trip during

the last trimester.

On long rides, 15 – 20 minute rest period every

2-3 hours to walk about or empty the bladder is

advisable.

Exercises

Chief Aim : To strengthen the muscles used in

labor and delivery

Should be done in moderation

Should be individualized: according to age,

physical condition, customary amount of

exercise and stage of pregnancy

Recommended Exercises

Squatting 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

Tailor

Sitting

Strengthens the thighs and

stretches perineal muscles to

make them more supple.

Pelvic Rock Maintains good posture

Relieve abdominal pressure

and low back pain

Strengthens abdominal

muscles

Modified

knee-chest

position

Relieve pelvic pressure and

cramps in the thighs and

buttocks

Relieves discomfort from

hemorrhoids.

Shoulder-

circling

Strengthens muscles of the chest

Walking BEST EXERCISE

Kegel Relieve congestion and

discomfort in pelvic region.

Tones up pelvic floor muscles

Prenatal ( Health Center) Handouts

Documents

mark fredderick r abejo

emergency care

care package

health risks potential

pregnancy reflux

pregnancy launch

lecture notes

allocation of health