saas

1. Health Care and Fetal
Assessment During Pregnancy
(Antenatal care)
By
Captain
Ala’a Ababneh

2. Preconception care
• Preconception care is health care and screening
conducted before pregnancy occurs so that medical risk
factors or life style behaviors can be identified, managed,
or changed before pregnancy.
• Most woman who seek medical care as soon as they
realize that they are pregnant.
• Most birth defects occur between 2 to 8 weeks of
gestation.
• Ideally prenatal care occur before pregnancy occur.
• Preconception care is best achieved when pregnancy is
planned.

3. Prenatal care
• Early and regular prenatal dramatically reduces infant
and maternal morbidity and mortality.
• Goals of prenatal care:
1. To support and encourage family’s healthy
psychological adjustment to child bearing.
2. To monitor the progress of pregnancy in order to
ensure maternal health and normal fetal development.
3. To recognize deviation from the normal and provide
management or treatment as required.
4. To ensure that the woman reaches the end of her
pregnancy physically and emotionally prepared for
delivery.

4. 5. Provide health education and advices to the
pregnant woman and her family.
6. To build up a trusting relationship.
7. To reduce infant and maternal mortality.
8. Provide physical assessment and care.
9. Educating about self care during pregnancy.
10. Teaching health habits that may be continued
after pregnancy.
11. Preparing parents for adaptation to
parenthood.

5. • Major emphasis is placed on preventive
aspects of care.
• The normal pregnancy depends on:
• Health status.
• Emotional status.
• Past health.

6. • Prenatal care is ideally a multidisciplinary
activity in which nurses work with
physicians or midwifes, nutritionists, social
workers, and others. Collaboration among
those individuals is necessary to provide
holistic care.

7. Cultural competence
• Cultural consideration are important in
caring for woman during pregnancy.
• The nurse must integrate the safe cultural
practices and accept this practice in
providing care.
• Should not be harmful to the mother or to
the fetus.

8. Prenatal visits
• Initial assessment interview can be
establish the trusting relationship between
the nurse and the pregnant woman.
• It is planned visits.
• Focuses on the subjective and objective
data.

9. Booking visits
• Visit should take place as soon as possible after
pregnancy has been confirmed.
• Aim of booking visits:
1. Assess levels of health by taking a detailed history and
screening tests.
2. To ascertain baseline recording the wt, ht, BP,
( used for comparison as pregnancy progressed).
3. Identify risk factors.
4. Give advice according to needs.
5. To provide an opportunity for the woman to express
any feeling or concerns about this pregnancy or
previous obstetric experience.

10. Initial health history
• Personal information, age, education, occupation, marital
status, nutritional hx.
• Woman and her family medical hx, to identify possible
health problems such as heart disease, genetic
disorders, DM, ….
• Obstetric and gynecologic history: data are gathered
on the woman’s age of menarche, menstrual history, and
contraceptive history, the nature of any infertility or
gynecologic conditions, and a detailed history of all her
pregnancy, including the present pregnancy, and their
outcomes. The data of the last pap test and the result
are noted. The date of here LMP is obtained to
established the EDB.

11. • Physical examination: the initial physical examination
provides the baseline for assessing subsequent
changes.
• The physical examinations begins with assessment of
vital signs and height and weight (BMI).
• The bladder should be empty before pelvic examination.
• You can choose the head to toe progression.
• Heart and lung sounds are evaluated.
• The thyroid gland is assessed.
• Pelvic examination.
• One vaginal examination during pregnancy is
recommended

12. • Laboratory tests: specimens are
collected at the initial visits so that the
cause of any abnormal findings can be
treated.
• Urine sample is obtained

13. Subsequent visits
• The initial visit usually occurs in the first
trimester, with monthly visits through
week 28 of pregnancy. Thereafter, visits
are scheduled every 2 weeks until week
36, and then every week till birth.

14. • Woman’s wt, BP, and urine checked for
protein acetone, and glucose monitored to
detect early hypertension and DM.
• Abdominal assessment estimation of the
gestational age through measurement the
height of the fundus.

15. • Fundal height: the fundal height,
measurement of the height of the uterus
above symphysis pubis, is used as one
indicator of fetal growth.
• From gestational weeks 18-32, the
height of the fundus in cm is
approximately the same as the numbers
of gestational weeks, with an empty
bladder.
• In addition fundal height measurement
may aid in the identification of high risk
factors.

16. o At 36 week fundal height reach xiphoid
process.
o Between 38-40 weeks fundal height drop
4cm from xiphoid process (as a result of
lightening).

18. • Abdominal palpation by using Leopold maneuvers
used to assess the presentation, position of the fetus.
• Fundus palpation; to determine what is the occupied
part head, breech.
• Lateral palpation: to determine the position of the fetus
back to hear the fetal heart sound.
• Pelvis palpation: palpate the lower pole of the uterus
just above pelvis, to determine the fetus part above the
symphysis pubis ( head, breach).
• Pawlik’s maneuver: the lower pole of the uterus is
grasped it the right hand  noting the position of
cephalic prominence.

20. • After obtaining information through the
assessment process, the data are
analyzed to identify deviations from the
norm and unique needs of the pregnant
woman and her family. Although
comprehensive health care requires
collaboration among professionals from
several disciplines, nurses are in an
excellent position to formulate diagnosis
that can be used to guide independent
interventions.

21. Risk factors arising during
pregnancy
1. Fetal movement pattern changed.
2. Decrease Hb level than 10g/dl.
3. Wt gain or loss.
4. Proteinuria, glycosurea.
5. BP above 140/90 mm/hg.
6. Uterus small or large for dates.
7. Excess or decreased liquor.
8. Mal presentation.
9. Head not engaged in prim woman by 38 weeks.
10. Vaginal bleeding.
11. Premature labor.
12. Vaginal infection.
13. Sever headache.

22. Factors that indicate the need for
intensified antenatal care.
1. Age less than 18 or above 35 years.
2. Primigravida above 35 years.
3. Grand multiparty.
4. Vaginal bleeding at any time during
pregnancy.
5. Uncertain EDD.

23. • Past obstetric history:
1. Still birth or neonatal death.
2. Small or large for dates.
3. Congenital abnormalities.
4. RH isoimmunization.
5. PIH, premature labor.
6. APH,PPH, precipitate labor.
7. abortions

24. • Maternal health:
1. Previous hx of DVT or pulmonary
embolism.
2. Chronic illness, increased BP, family hx
of DM.
3. Hx of infertility, uterine anomaly,
including fibroids.
4. Smoking more than 10 cigarettes/day.

25. • Booking examination:
1. BP 140/90 and above.
2. Wt above 85kg or less 45kg. Ht less than
150cm.
3. Cardiac murmurs, RH –ve, blood
disorders.
4. Pelvic mass, and shoe size less than35.

26. Education for self-care

27. Personal hygiene
• Excessive sweating and perspiration,
vaginal secretion.
• Baths and warm showers can be
therapeutic because they relax tense, tired
muscles, help counter insomnia, and make
the pregnant woman feel fresh.
• Tub bathing is contraindicated after
rupture of membranes.

28. Prevention of UTI
• The nurse can assess the woman’s
understanding and use of good hand washing
techniques before and after urination and the
importance of wiping the perineum from front
to back . Soft, absorbent toilet tissue,
preferably white and unscented, should be
used.
• Woman should wear cotton underpants and
avoid wearing tight fitting jeans for long
periods, anything that allows a buildup of heat
and moisture in the genital area may foster
the growth of bacteria.

29. • The nurse should advise the pregnant
to drink at least 2 L of liquid a day,
preferably water, to maintain adequate
fluid intake that ensures frequent
urination.
• The consumption of yogurt and
acidophilus milk also may help prevent
urinary tract and vaginal infections.
• Women are told not to ignore the urge
to urinate.
• They always should urinate before
going to bed at night.
• Drinking cranberry juice.

30. Kegel exercise
• Kegel exercise , deliberates contraction and
relaxation of the pubococcygeus muscle,
strengthen the muscles around the
reproductive organs and improve muscle
tone.
• The muscles of the pelvic floor encircle the
vaginal outlets, and they need to be
exercised, because exercised muscle can
then contract and stretch readily at the time of
birth.
• Practices of pelvic muscle exercises during
pregnancy also result in fewer complaints of
urinary incontinence in late pregnancy and
postpartum.

31. Preparation for breastfeeding
Nipple preparation
- the women are taught to cleanse the
nipples with warm water to keep ducts from
being blocked.
- soap, ointment, & alcohol should not be
applied.
Colostrum if any dropping place pads inside
the bra and keep them dry.
• Exercise to erect inverted nipple in the last
2 months of pregnancy.

32. Physical activity
• Physical activity promotes a feeling of
well being in the pregnant woman. Its
improves circulation and oxygnation,
promote relaxation and rest, and
counteracts boredom, as it dose in the
nonpregnant woman.
• 30 minutes of moderate physical
exercise is recommended ( ACOG).

33. Exercise
In an RCT that compared babies born to
women who continued regular exercise
during pregnancy with women who did not
exercise regularly during pregnancy, no
differences in neuro developmental
outcomes at one year of age were
reported.
Aerobic physical activity in pregnancy may
be an important determinant of birth
weight within the normal range, especially
in taller mothers . (Kramer et al 2004)

34. Lifestyle practices of Jordanian pregnant women
(M. Gharaibeh,2005)
Purpose: To describe the health-promoting
lifestyle behaviors of Jordanian pregnant women.
METHODS sample of 400 Jordanian pregnant
women in their 20th week of gestation or beyond
were recruited from five public Maternal and
Child Health Centers in the city of Irbid, in the
northern part of Jordan.
Results: The women reported high scores on
health responsibility and self-actualization,
moderate scores on interpersonal support and
nutrition, and low scores on physical activity and
stress management behaviors.

35. Rest and relaxation
• The side lying position is recommended
because it promotes uterine perfusion and
fetoplacental oxygenation by eliminating
pressure on the ascending vena cava and
descending aorta, which can lead to
supine hypotension.

36. Employment
• Employment of pregnant women usually has
no adverse effects on pregnancy outcomes.
• However, some job environment pose
potential risk to the fetus.
• Women with sedentary jobs need to walk
around at intervals. They should not stand in
one position for long periods, and they should
avoid crossing their legs at the knees,
because all activities can foster the
development of varices and thrombophlebitis.
Standing for long periods also increases the
risk of preterm labor. The pregnant woman’s
chair should provide adequate back support.

37. clothing
• Comfortable, loose clothing is recommended.
• Tight bra and belts, stretch pants, and
another constrictive clothing should be
avoided because tight clothing over the
perineum encourages vaginitis, and impaired
circulation in the legs can cause varicosities.
• Maternity bra are constructed to
accommodate the increased breast weight,
chest circumference, and the size of breast
tail tissue. These bra also have drop flaps
over the nipples to facilitates breastfeeding. A
good bra can help prevent neck ache and
backache.

38. • Comfortable shoes that provides firm
support and promote good posture and
balance also advisable.
• Very high heels are not recommended.

39. Immunization
• Immunization with live or attenuated live
viruses is contraindicated during
pregnancy because of its potential
teratogenicity but should be part of
postpartum care.
• Vaccines consisting of killed viruses
may be used.

40. Dental care
• Use soft tooth brush, continue routine daily
dental care, avoid any radiological
procedure unless there is an indication.

41. Cigarette smoke, caffeine, and
drugs.
• Pregnant woman should be encouraged to
limit caffeine intake to no more 3 cups of
coffee or cola per day.

42. Tips on giving up smoking
1. Delay each cigarette for as long as
possible.
2. Find something to keep the hands
occupied.
3. Use chewing gum.
4. Only smoke when sitting down.
5. Reward oneself for success.

43. Normal discomforts
• Women pregnant for the first time have
an increased need for explanation of the
cause of the discomforts and for advice
on ways to relieve them.
• Nurses can do much to allay a first time
mothers anxiety about such symptoms
by telling her about them in advance
and using terminology that the woman
can understand.
• Understanding the rational for treatment
promotes their participation in their care.

44. Preparation for labor
prenatal birth classes should be initiate at the 3rd
trimester to provide the gravidas with following
information:
 Process of labor.
 Plans to get hospital.
 Methods of control pain.
 Supplies to have in a suitcase ready for
the trip to the hospital.
 Emergency arrangement.

45. Specific challenges facing maternal health development in Jordan
were identified in a joint MOH/WHO consultation on health
strategies in Nov 2002.
1-Decline in general economic and social
conditions limit the ability of families to
cover the cost of health care.
2-Inadequate awareness on importance of the
pre and post natal care.
3-Discrepancies in the quality and
effectiveness of health care services among
the governorates.

46. 4-The negative impact of poverty on accessibility to quality health care,
particularly in view of the high proportion of un insured people.
5-Inadequate coordination and partnership between health service providers
and educational institutions for health professionals.
6-Rapid advances in technology and rising health care costs and lack of
instruments for rational technology selection and assessment.
7-Increasing demands and expectations of the public for effective and
accessible health care.
8-Lack of health system research as an integral part of national health
development.
9-Nurses, midwifes are not necessarily educated at the graduate level.
10-Lack of system for receiving feedback on referral for pregnant
developed complications or for clients seeking family planning
methods not available at certain antenatal center.
By quality assurance best practice
MOH(2004)