NURSE-MANAGED PREGNANCY CARE IN THE COMMUNITY

Terms used for maternal assessment:

1. Gravida- refers to a pregnant mother 2. Gravidity- refers to the number of pregnancies. 3. Nulligravida- is a woman who has never been pregnant. 4. Primigravida- is a woman who is pregnant for the first time 5. Multigravida- is a woman in atleast her second pregnancy. 6. Parity- is the number of births (not the number of fetuses or twins) past 20 weeks of gestation, whether the fetus was born alive or not. 7. Nullipara- is a woman who has not had a birth at more than 20 weeks of gestation. 8. Primipara- is a woman who has had one birth that occurs after the 20th week of gestation. 9. multipara- a woman who had two or more births resulting in variable offspring.

GTPAL
G- gravity; number of pregnancies T-term births; the number born at term (40 weeks) P-preterm births; the number born before 40 weeks gestation A-abortions/miscarriages; number of abortions, included in gravida if before 20 weeks of gestation, included in parity if past 20 weeks gestation. L-live births, the number of live births or living children

THE MATERNAL HEALTH PROGRAM



The overall goal of the program of the DOH is to improve the survival, health and well-of mothers and unborn through a package of services for the pre pregnancy, pre natal, natal and post natal stages. The standard prenatal visits during pregnancy:

Prenatal visits 1st visit 2nd visit 3rd visit Every 2 weeks

Period of pregnancy As early in pregnancy during 1st trimester During the 2nd trimester During the 3rd trimester After 8th month of pregnancy till delivery

The DOH Motherhood Supervisory Flowchart (2003) suggests the following activities for the prenatal visits:
First trimester (4-16 wks) 1. Compute AOG (Age of gestation) using the fundic height & EDC (expected of confinement) How to measure Fundic Height: >Place the client in a supine position >Place the end of the tape measure at the level of the symphysis pubis > Stretch the tape to the top of the uterine fundus. > Note and record the measurement.


Formula in computing EDC using the Nageles Rule: >Add 7 days to the first day of the last menstrual period, subtract 3 months, and then add 1 year. Example: First day of LMP: September 11, 2006 Add 7 days: September 18, 2006 Subtract 3 months: June 18, 2006 Add 1 year: June 18, 2007 Estimated date of confinement: June 18, 2007

2. Physical examination and vital signs 3. Screening for medical problems and danger signs (initiate first aid measures as needed & refer to physician. 4. Provide routine pregnancy care: 1. Iron supplement 2. Low dose Vit. A 3. Tetanus toxoid 4. Malaria prophylaxis for endemic areas 5. CBC, Urinalysis

Cont
5. Provide counseling messages and initialize birth plan: >Nutrition and hygiene >Discomforts in pregnancy >Dos and donts in pregnancy >Warning signs in pregnancy >Fertility awareness and Family Planning >Breastfeeding, Child care and family health >Delivery and emergency preparations Schedule 2nd prenatal visit and update HBMR

Discomforts of pregnancy
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Nausea and vomiting Syncope Urinary urgency and frequency Breast tenderness (increase estrogen and progesterone) Increased vaginal discharges Nasal stuffiness (due to increase in estrogen) Fatigue (due to hormonal changes) Heartburn (increase in progesterone, decrease gastric motility and displacement of the stomach) Ankle edema Varicose veins Headache (due to increase in blood volume and vascular tone) Hemorrhoids (due to increased venous pressure and constipation) Backache (due to exaggerated lumbosacral curve)

Danger signs of pregnancy

1. 2. 3. 4. 5. 6. 7. 8.

Hypertension Headache Blurring of vision or visual changes Excessive proteinuria Generalized edema and puffiness Epigastric pain Decreased urinary output bleeding

Second trimester (17-28 weeks)

Validate AOG & EDC; update HBMR 2. Physical examination, fundic height, quickening and vital signs 3. Screen for danger signs: 4. Screen for: >pre-eclampsia (20th wk > gestational diabetes (24th week) 5. Urinalysis and random blood sugar, if available
1.

Cont.
6. Provide 1st aid measures as needed & refer physician 7. Provide routine pregnancy care: >Iron supplement >Low dose >Vitamin A supplement >Tetanus toxoid immunization 8. Provide counseling messages & review birth plan: >Nutrition and hygiene >Discomforts in pregnancy >Dos and donts in pregnancy > Warning signs in pregnancy >Breastfeeding, Child care and family health > Delivery and emergency preparations Schedule 2nd prenatal visit and update HBMR If this is the 1st trimester activities have been done

Third Trimester (29-40 weeks)

1. 2. 3. 4.

5.

Validate AOG through measurement of fundic height and confirm EDC; update HBMR Physical examination, vital signs, fundic height, fetal heart rate Screen for danger signs Screen for painless vaginal bleeding (placenta previa), preterm labor, headache, puffiness, edema, painful vaginal bleeding (abruptio placenta) Provide routine pregnancy care: 1. Iron supplement 2. Vit. A supplement 3. Tetanus toxoid

Cont.
6. Provide counseling messages and validate birth plan: >Nutrition and hygiene >Dos and donts in pregnancy >warning signs in pregnancy >fertility awareness and FP >Breastfeeding, Child care and family health >Delivery and emergency preparations >Personal hygiene after delivery Schedule 4th prenatal visit preferably 1-2 weeks before delivery.

COMPONENTS OF PREGNANCY CARE

1.

Weight and height > weight is taken every visit > gradual increase is important esp during 2nd and 3rd trimester > inadequate weight increases the risk of having low birth weight baby less than (2500 grams). > a too high weight gain also increases the risk of having an overweight baby. > typically, a 2-5 pounds weight gain is expected in the 1st trimester.

> thereafter, the increase is expected to be 1 pound/week for normal weight, more then 1 pound/wk for underweight and .66 pound/week for the overweight. > there should be no dieting or weight reduction during pregnancy. > weight gain can be estimated through pre pregnancy BMI (Body Mass Index) weight in kgs. divided by the square of height in meters (kg)/height (m2). > Height in cm is also measured, women with height less than 145 are usually at risk for delivery complications.

2. Blood pressure and edema

The blood pressure is the most sensitive screening test for diagnosing hypertensive disorders in pregnancy with a 71% sensitivity, 95% specifically and 40% predictive value for preeclampsia in pregnancy, labor and puerperium.

MEAN
Systolic >130 130-139 140-159 160-179 180-209 >210 Diastolic >85 85-89 90-99 100-109 110-119 >120

BP CLASSIFICATION

Normal High normal Stage 1 Stage 2-moderate Stage 3-severe Stage 4- very severe

Dependent edema is common in normal pregnancy, while generalized edema is seen in pre-eclampsia. Edema is best assessed on the face, hands and sacrum and taken in conjunction with blood pressure readings. Abnormal findings warrant referral to the physician.

3. Leopolds Maneuver  Helps determine the number of fetuses, fetal lie, position and presentation. It is more accurate when done at the last weeks of pregnancy and before labor.

4. Fundic height
is taken after th 20th week from the symphysis pubis to the fundus using a non-expendable tape and measured in the subsequent visits. Taken in centimeters, it is a good estimate of th age of gestation in weeks in the HBMR of the DOH, the ff. estimates are used: 5th month: 20 cm 6th month: 21-24 cm 7th month: 25-28 cm 8th month: 29-30 cm 9th month: 30-34 cm When the measurement is 3 cm more or less than the estimates above, the woman is referred to the physician.

5. Fetal heart tone

is counted for one (1) full minute with the use of a stethoscope on the 5th month and during all the subsequent visits. The normal rate is 120-160 bpm. Absence of FHT or signs of fetal distress are reported to the physician.

6. Dietary advise and information

The following information should be emphasized during visits: 1. Proper nutrition affects fetal development and birth 2. Pre-pregnancy status and weight gain during pregnancy are correlated with infant birth weight. 3. Caloric requirements do not increase until the 2nd trimester, normal weight women need additional 300 calories.

7. Thyroid gland examination

This is best done by palpation of the thyroid gland. The importance of this examination is based on the report that 30% of pregnant women have goiter. 8. Anemia is a condition that develop as a result of iron deficiency. This predispose the client to postpartum infection and hemorrhage.

Signs and symptoms:

1. Fatigue 2. Headache 3. Pallor 4. Tachycardia 5. Hemoglobin value <10 g/dl, hematocrit <30 g/dl

Medical and nursing management of anemia: 1. HBMR gives standard prescription for filipino women to take iron/folate supplement twice a day (60 mg/tablet) starting on the 5th month of pregnancy to 2 months postpartum. 2. Instruct the client to take vitamin C along with iron for better absorption. 3. Monitor hemoglobin and hematocrit every month until stable.

4. Eat foods high in iron, folic acid and protein. 5. Expect to administer oxytoxic medications in the postpartum period to prevent hemorrhage.


All pregnant women in malaria infested areas shall be given prophylaxis of Chloroquine (150 mg base tablet) at 2 tablets/week for the whole duration of pregnancy.

9. Danger signs of pregnancy

Vaginal bleeding or postpartum hemorrhage Is an excessive loss of blood which occurs early (within first 24 hrs) or late 24 hrs or <6 wks after birth) Normal blood loss after delivery: Type of delivery volume of blood loss Vaginal delivery 500 ml Cesarean delivery 1,000 ml Cesarean with hysterectomy 1,500 ml
1.

2. Edema of the face and hands- this is an early sign of pregnancy-induced hypertension in an acute hypertensive state. Other signs includes hypertension and proteinuria. Medical/nursing mgt: 1. Monitor blood pressure and weight. 2. Increase dietary intake of protein and carbohydrates. 3. Adequate fluid intake.

3. Headache, dizziness and blurring of vision- this will be a symptoms of impending preeclampsia which a complication of pregnancyinduced hypertension (PIH). The nurse needs to have the skill in detecting the danger signs of pregnancy. Patients manifesting these signs need to be referred to the nearest facility or physician.

10. Breastfeeding
World Health Organization (WHO) is strongly pursuing advocacy in promoting breastfeeding as the best form of infant feeding for the first six months. During the early prenatal visits, ff. are recommended: 1. Identify personal and demographic information that can affects breastfeeding decision (example: work, socioeconomic status, prior exposure to breastfeeding). 2. Assess breast and nipples for conditions that can promote or hinder breastfeeding. 3. Provide information on how to manage breastfeeding problems. 4. Assist to identify breastfeeding goal and plan. 5. Facilitate feeding (ideally within the first 2 hrs.) rooming in; unrestricted breastfeeding 8-12 times/24 hours.

11. Family Planning

The need to make a decision on family planning is done during pregnancy. Contraception is discussed on the 7th visit or the 36th week. This provides ample time for the couple to choose a family planning method before delivery.

METHODS OF NURSE-CLIENT CONTACT

Two important contact: Clinic visits- Provides easy access to supplies, facilities, and assistance to other members of the health team. Home visits- generally done as a referral from a professional health worker. There are three phases of the home visit: Preparatory phase Home visit Post visit phase

1.

1. 2. 3.

PREPARATORY PHASE Review records/referral data Prepare equipment, supplies Ensure safety requirements (ex. Infection control) Notify client/family of the visit 1. Introduce self. 2. Discuss the purpose of visit, activities 3. Set an appointment (date and estimated duration of the visit) ACTUAL HOME VISIT Introduce self State the purpose if 1st visit and set another date for the appointment. 1. Discuss the activities for the visit. (ex. Make schedule convenient to family. 2. Perform assessment. 3. Share assessment findings with the client/family

4. Together with the client/family, determine expected outcomes, make a plan of care, agreements. 5. Carry out interventions/activities; seek the participation of the family caregivers, as needed. 6. Summarize decisions made/learning outcomes/ and family responses to care. 7. Set the schedule of the next visit with the family. 8. Inform the client/family of referrals and need by interdisciplinary services communication system. Ensure practice of safety precautions

POST VISIT Recording of data on the chart 1. Assessment data and nursing diagnosis 2. Plan of care 3. Interventions done 4. Outcomes of visit: responses, problems, concerns. 5. Other significant information for follow-up; schedule of next visit Facilitating referrals (to other health professionals or agencies)