Lecture Notes on Prenatal Care / Health Teachings

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

Clinical Instructor

1
Heartburn

Increased
progesterone
which dec.
gastric
motility
causing
esophageal
reflux.

Constipation

Due to
displacemen
t of the
stomach and
intestines;
iron
supplements

Hemorrhoids

Pressure of
growing
fetus,
Increase
venous
pressure

Urinary
Frequency

Increase
blood supply
to the
kidney/
Pressure of
enlarged
uterus in the
3rd Tri
From
exaggerated
lumbosacral
curving
during
pregnancy.

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
Hegars Sign
Goodells Sign
Chadwicks Sign
Ballottement
Braxton Hicks contraction
Positive Pregnancy Test
Positive Signs
Fetal Heart Tone
X-ray or Ultrasound of fetus
Palpable fetal movements
Discomforts of Pregnancy
Changes
Nausea and
Vomiting

Reason
Increased
HCG

Health
Teachings
Dry crackers
30 min. before
arising
Small,
frequent, low
fat meals
Liquids bet.
meals
Avoid antiemetics.

Backache

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
Increased
fluids and
roughage in the
diet.
Regular
elimination
time.
Increase
exercise
Avoid enemas,
harsh laxatives
and mineral oil.
Warm sitz
bathing
High fiber diet
and increase
fluid.
Sit on soft
pillow
Sleep on the
side at night.
Limit fluid
intake during
evening
Bladder
training
Back exercise
(pelvic rock)
Wear lowheeled shoes.
Avoid heavy
lifting

Lecture Notes on Prenatal Care / Health Teachings

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

Leg Cramps

Increase
pressure of
gravid fetus,
low calcium

Ankle Edema

From
venous
stasis

Varicose
Veins

From faulty
valves or
weakened
vessel walls

Shortness of
breath

From
pressure on
diaphragm
Elevated
Estrogen
levels

Nasal
stuffiness and
epistaxis

Fatigue

Due to
hormonal
changes

Breast
Tenderness

Increase
estrogen and
progesterone
level
Due to
hyperplasia
of mucosa
and increase
mucus
production

Increased
Vaginal
discharges

2
Frequent rest
with feet
elevated
Regular
exercise like
walking
Increase milk
intake
Elevate legs at
least twice a
day.
Sleep on left
side
Elevate feet
when sitting.
Use support
hose
Apply elastic
bandage
Avoid use of
constricting
garters
Sleep with feet
elevated or on
regularly.
Direct pressure
to the nasal
area
Avoid blowing
of nose.
Get regular
exercise
Sleep as much
as needed.
Avoid
stimulants.
Wear well
fitted bra
Warm
compress
Consult
physician if
infection is
suspected
Wash carefully
and keep it dry.

Presumptive Signs of Pregnancy

Lecture Notes on Prenatal Care / Health Teachings

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

Formula Used In Providing Estimates In

Pregnancy
A. To estimate the EDC
Given the
Last Menstrual
Period (LMP)

Use
Nageles Rule

Date of
Quickening

Formula
First day of
LMP 3
months + 7
days
Primi:
Q + 4 months
+ 20 days
Multi:
Q + 5 months
+ 4 days

B. To estimate the AOG

Given the
Fundic Height

Use
McDonalds
rule

Formula
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

Given the
Rump-tocrown length
in utero cm.

Use
Standard
Formula

Johnsons
Ruler

Formula
Rump-to-crown
length in utero cm.
x 100 = weight in
gm
FH (cm)
- 11 (if unengaged )
- 12 ( if engaged ) x
155

Measuring the Fundic Height

Lecture Notes on Prenatal Care / Health Teachings

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

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 womens exposure to health risks
through the institutionalization of responsible
parenthood and provision of appropriate health
care package to all women of reproductive ages.
LGUs, 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 ( 49)
- 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,

Lecture Notes on Prenatal Care / Health Teachings

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

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 persons 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:
Hegars Sign softening of the uterus
Goodells Sign softening of the cervix
Chadwicks 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

Lecture Notes on Prenatal Care / Health Teachings

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

6
Classification of Findings

Pelvic Measurement are preferably done

th

after the 6 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.

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

Types of Pelvis
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.

Papanicolau ( Pap Smear)

cytological examination to
diagnose cervical cancer.

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

Lecture Notes on Prenatal Care / Health Teachings

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

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.

7
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

Procedure:

1st 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.
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 )

4th Maneuver

2nd 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.

Lecture Notes on Prenatal Care / Health Teachings

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

Benedicts 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

8
Nutritional Assessment
- Food preferences and eating habits
- Cultural and religious influences
- Education and occupational level

Assessing Maternal Weight Gain

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.
Computation of Caloric Equivalents
Women who need special attention:
Pregnant teenagers
Low pre-pregnant weight and obese
Low income women
Successive pregnancies
Vegetarians

Carbohydrates X 4
Proteins X 4
Fats X 9

Lecture Notes on Prenatal Care / Health Teachings

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

Lecture Notes on Prenatal Care / Health Teachings

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

10

Food Sources
Protein
Vit. A
Vit. D

Vit. E
Vit. C
Folic Acid
Vit. B
Calcium and
Phosphorus
Iron

Iodine

Meat, fish, eggs, milk, poultry,

cheese, beans, mongo
Eggs, carrots, squash, all green
leafy vegetables
Fish, liver, egg, milk, margarine
Note: excess vit.D may lead to
fetal cardiac problem
Green leafy vegetables, fish, corn
Tomatoes, guava, papaya, citrus
fruits
Asparagus, organ meat, green
leafy vegetables
( foods rich in protein )
Milk, cheese, green leafy
vegetables, whole grains,
seafood, tofu
Pork liver, lean meat, kamote
leaves, soybeans, seaweeds,
mongo
Iodized salt, seafood, milk, egg,
bread

Micronutrient Supplementation
Vitamin A Supplementation
Target
Prep.
Pregnant 10,000
IU
Women

Post
Partum
Women

Dose
1
cap
2x a
week

200,000 1
IU
cap

Duration
Start from
the 4th
month of
pregnancy
until
delivery

One dose
only
within 4
weeks
after
delivery

Remarks
Vit. A
should
not be
given to
woman
who
already
taking
vit. that
also
contain
Vit. A
Vit.A
(200K
IU)
should
not be to
pregnant
women.

10,000
Pregnat
IU
women
with
night
blindness

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
1 tab/day for
Pregnant Coated
Tab.
6 months or
Women
contains 180 days
60 mg
during
elemental pregnancy
iron with period
400 mg
OR
folic acid 2 tab/day if
prenatal
consultation
are done
during the
2nd/3rd
trimester
1 tab / day for
Lactating Coated
Tab.
3 months or
Women
contains 90 days
60 mg
elemental
iron with
400 mg
folic acid

Remarks

A dose of
800 mcg
folic acid
is still
safe to
pregnant
woman

Iodine Supplementation
Target
Women
15-45
yrs.old

Prep.
Iodized oil
capsule with
200 mg.
iodine

Dose / Duration
1 capsule for 1
year

Lecture Notes on Prenatal Care / Health Teachings

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

11

TeTox Routine Immunization of

Pregnant Women

Donts During Pregnancy

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
are
dangerous
Drugs
st
especially during 1 Tri.
Causes amelia or
Thalidomide
phocomelia (short or no
extremities
Can cause cleft palate and
Steriods
abortion
Can cause enlargement of
Cough
fetal thyroid gland leading
suppressant
to tracheal compression and
dyspnea at birth
Cause hemolysis and
Vit.K
hyperbilirubinemia
Causes bleeding disorder
Aspirin
Cause damage to the 8th
Streptomycin
cranial nerve
Causes staining of the tooth
Tetracycline
enamel and inhibits growth
of long bones
Causes abruption placenta,
Cocaine
preterm labor and fetal
death
Amphetamines Can cause jitteriness and
poor feeding at birth
Increase incidence of
Marijuana
respiratory infection
Small gestational age,
Narcotics
increase rate of fetal distress,
meconium aspiration,
abnormal fetal liver and lung
tissue
Cardiac irregularities,
Inhalants
severe respiratory
depression.
Smoking

Vaccine

Minimum
Interval

TeTox 1

As early as
possible
during
pregnancy
4 weeks
after
TeTox 1

TeTox 2
Minimum
required
TeTox for
pregnant
mother

Percent
Protected

80%

TeTox 3

6 months
after
TeTox 2

95 %

TeTox 4

1 year
after
TeTox 3

99 %

TeTox 5 1 year after

TeTox 4

99 %

Duration of
Protection

infant will
be
protected
by neonatal
tetanus
3 years
protection
for the
mother
infant will
be
protected
by neonatal
tetanus
5 years
protection
for the
mother
infant will
be
protected
by neonatal
tetanus
10 years
protection
for the
mother
all infant
born to that
mother will
be
protected
lifetime
protection
for the
mother

Lecture Notes on Prenatal Care / Health Teachings

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

12

Sexual Activity
Traveling
Sexual desires continue
pregnancy, but levels change:

throughout

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 (dogs 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.

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

Tailor
Sitting
Pelvic Rock

Modified
knee-chest
position

Shouldercircling
Walking
Kegel

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
Strengthens the thighs and
stretches perineal muscles to
make them more supple.
Maintains good posture
Relieve abdominal pressure
and low back pain
Strengthens abdominal
muscles
Relieve pelvic pressure and
cramps in the thighs and
buttocks
Relieves discomfort from
hemorrhoids.
Strengthens muscles of the chest
BEST EXERCISE
Relieve congestion and
discomfort in pelvic region.
Tones up pelvic floor muscles