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Chapter Summary of Piliteri's Assessment of Maternal and Fetal Health 

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Chapter Summary of Piliteri's Assessment of Maternal and Fetal Health 

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Prenatal care

Essential for ensuring overall health of newborns and their mothers

A major strategy for helping to reduce complications of pregnancy such as number of low-birth-weight babies born yearly

Begins during a woman’s childhood

Includes balanced nutrition with adequate intake of calcium & vitamin D

Adequate immunizations against contagious diseases and maintenance of an overall healthy lifestyle is also included to ensure best state of health

Lack of prenatal care is associated with the birth of preterm infants and various complications for a woman such as hypertension of pregnancy

Purposes of prenatal care

Establish a baseline of present health

Determine the gestational age of the fetus

Monitor fetal development and maternal well-being

Identify women at risk for complications

Minimize the risk of possible complications by anticipating and preventing problems before they occur

Provide time for education about pregnancy, lactation, and newborn care

Several National Health Goals speak directly to the importance of prenatal care

Increase the proportion of pregnant women who receive early and adequate prenatal care from a baseline of 74% to a target of 90%

Increase the proportion of pregnant women who attend a series of prepared childbirth classes from a baseline of 66% to a target of 77%

Increase to at least 90% the proportion of all pregnant women who receive prenatal care in the first trimester of pregnancy from a baseline of 83% (http://www.nih.gov)

Nursing Process
1. Assessment

First prenatal visit is a time to establish baseline data relevant to health assessment and health-promotion strategies

Begins with obtaining health history, including screening for presence of teratogens

Explaining why specific assessment data are relevant to the pregnancy is important

Relay assessment information to help keep a woman and her family well informed

2. Nursing Diagnosis

Usually focuses on the response of a woman and her family

Decisional conflict related to desire to be pregnant and risk for ineffective coping related to confirmation of unplanned pregnancy would be an example

Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy is a nursing diagnosis appropriate to prenatal care

3. Outcome Identification and Planning

Be certain to reserve sufficient time at prenatal visits so care can be thorough

There should be enough time to set realistic goals and expected outcomes

Establishing a pattern of regular appointments is crucial to providing effective prenatal care

Reliable Internet sites to use for referral on preconceptual or prenatal care are the National Institute of Health and Human Development

4. Implementation

Teaching women and their families about a safe pregnancy lifestyle is an important nursing intervention

It may be helpful to give a woman and her partner pamphlets or books that cover the same topics

Be certain that you have read all the printed material you give families to ensure that a pamphlet’s advice is consistent with what you have said and with the views of a woman’s primary care physician or nurse-midwife

5. Outcome Evaluation

Evaluation during prenatal visits should concentrate on a woman’s initial progress

Couple state they have reached a mutual decision to both stop smoking is an example of expected outcome

The Preconceptual Visit

Ideally, women should schedule an appointment with a physician or nurse-midwife

This is done to obtain accurate reproductive life planning information, receive reassurance about fertility, and detect any problems that may need correction

Consists of thorough health history, and physical and pelvic examinations

A woman can be counseled on the importance of a good protein diet

Choosing a Health Care Provider for Pregnancy and Childbirth

Once a woman is or suspects that she may be pregnant, her next step is to choose a primary health care provider

Various options are available, including a prenatal clinic, her health maintenance organization (HMO) or preferred provider (PPO)

Regardless of the type of health care provider chosen, prenatal care needs to be initiated early and continued throughout pregnancy

Nurses contribute to the success of prenatal care by listening, counseling, and teaching, three areas of nursing expertise

Health Assessment During the First Prenatal Visit

An important focus of all prenatal visits is to screen for danger signs that might reveal any risky conditions

Screening includes an extensive health history, a complete physical examination, including a pelvic examination, and blood and urine specimens for laboratory work. Manual pelvic measurements can be taken to determine pelvic adequacy

The Initial Interview

Good interviewing technique is important to obtain thorough and meaningful health histories

Interviewing expectant women often elicits contradictory information

Interviewing them should go smoothly and be productive

It is best accomplished to interview in a private, quiet setting

Components of the Health History
An initial interview serves several purposes:

Establishing rapport

Gaining information about a woman’s physical and psychosocial health

Obtaining a basis for anticipatory guidance for the pregnancy

Demographic Data

Demographic data usually obtained include name, age, address, telephone number, e-mail address, religion, and health insurance information.

Chief Concern

The chief concern is the reason a woman has come to the health care setting.

Family Profile

Obtaining this information early in an interview can help you get to know a woman earlier, identify important support persons, shape the nature and kind of questions to be asked, and evaluate the possible impact of a woman’s culture on care.

History of Past Illnesses

Questions about a woman’s past medical history are an important part of an interview because a past condition can become active during or immediately following pregnancy.

History of Family Illnesses

A family history documents illnesses that occur frequently in the family and so can help identify potential problems in a woman during pregnancy or in her infant at birth.

Day History/Social Profile

Information about a woman’s current nutrition, elimination, sleep, recreation, and interpersonal interactions can be elicited best by asking a woman to describe a typical day of her life.

Gynecologic History

A woman’s past experience with her reproductive system may have some influence on how well she accepts a pregnancy.

Obstetric History

For each previous pregnancy, document the child’s sex and the place and date of birth.

Review of Systems

a review of systems completes the subjective information

it helps women recall concerns they forgot to mention earlier

use a systematic approach, such as head to toe, and explain what you will be doing

Conclusion

End an interview by asking if there is something you have not covered that a woman wants to discuss.

Pelvic Assessment

common pelvic types include gynecoid (well-rounded with a wide pubic arch), anthropoid (narrow), platypelloid (flattened), and android (male or with a sharp pubic arch)

a gynecoid pelvis is ideal for childbearing

Points to remember

the true conjugate (conjugate vera) is the measurement between the anterior surface of the sacral prominence and the posterior surface of the inferior margin of the symphysis pubis (the anterior-posterior diameter of the pelvic inlet) the average is 10.5 to 11 cm

the ischial tuberosity diameter is the distance between the ischial tuberosities or the transverse diameter of the outlet the average is 11 cm

Pelvic Examination

Pregnant women should remain in a lithotomy position for as short a time as possible to help prevent thromboembolism and supine hypotension syndrome.

Danger signs

Danger signs for women to report during pregnancy are vaginal bleeding, persistent vomiting, chills and fever, escape of fluid from the vagina, abdominal or chest pain, swelling of the face and fingers, vision changes or continuous headache, burning with urination, or a pronounced decrease in fetal movement.

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4 P's of Labor:

1. Passage - should be adequate in size & contour

2. Passenger - should be appropriate in size & in an advantageous position & presentation

3. Power of labor - should be adequate

4. Woman's psyche - should be preserved, so that afterward labor can be viewed as a positive experience

A point to remember:

Each contraction squeezes the blood vessels that supply the placenta, thereby decreasing the amount of oxygen that flows to the fetus. The relaxation period allows the vessels to fill with oxygen-rich blood to supply the placenta.

3 Theories of Labor Onset (a result of changes in the following hormones/chemicals)

1. Decrease in PROGESTERONE

2. Release of OXYTOCIN

3. Production of PROSTAGLANDINS

Preliminary Signs of Labor:

Lightening

Braxton-Hicks Contractions

Nesting Instinct

Ripening of Cervix

Weight loss

Bloody show

Rupture of membranes

True Labor signs:

Uterine contractions

Show

Rupture of membranes

Mechanisms of labor:

Descent -  a continuous process from engagement until birth

Flexion - nodding of the fetal head toward the chest.

Internal Rotation - occipitotransverse to the occipito anterior position while descending

Extension - begins when the head crowns to head passing under the symphysis pubis

External Rotation (Restitution) -  realignment of the fetal head with the body after the head emerges

External Rotation (Shoulder Rotation) - shoulders externally rotate after the head emerges and restitution occurs

Expulsion - birth of the entire body

Duration of labor:

1. Primipara - 14 to 20hrs

2. Multipara - 8 to 14

Fetal Presentation

Refers to the foremost part of the fetus that enters the pelvic inlet.

Fetal attitude: Degree of Flexion
Good Attitude

Advantageous for birth because it helps the fetus present the smallest AP diameter of the skull to the pelvis

Also puts the whole body into an ovoid shape, occupying the smallest space possible o Complete flexion: spinal column bowed forward, head is flexed forward, chin touches the sternum, arms are flexed & folded on the chest, thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs

Complete flexion

The most common attitude; most favorable for vaginal birth; - Skull smallest diameter to the bony pelvis: Sub-occipto bregmatic

Stages of labor

1. First - active labor to full cervical dilatation

2. Second - full cervical dilatation to delivery of infant

3. Third - delivery of infant to delivery of placenta

4. Fourth - delivery of placenta up to 1-4 hrs

Fetal lie

Relationship between the spine of the fetus to the spine of the mother; whether the fetus is lying in a horizontal (transverse) or vertical (longitudinal) position. 99% assume a longitudinal lie.

Cephalic

Most frequent type, 95%

4 types: vertex, face, brow & mentum presentation

Vertex is the ideal part because the skull is capable of molding

Effectively; aid in cervical dilatation & prevents complications such as prolapsed cord.

Fetal skull that contacts the cervix becomes edematous (capput succedaneum) due to continued pressure against it.

Shoulder

Fetus lie horizontally (transverse) in the pelvis – longest fetal axis is perpendicular to that of the mother, 1% of births

Presenting part is usually the acromion process, iliac crest or elbow.

Caused by: relaxed abdominal walls, pelvic contraction, placenta previa (placenta located low in the uterus).

Must be born by caesarian birth

A point to remember:
In true labor, contractions are accompanied by cervical dilatation and effacement.

Fetal Station

How far the presenting part descended into the pelvis

Ischial spines→ 0 station “engaged”

Above ischial spines→ negative

Below ischial spines→ positive

+3-+4 crowning

Molding

Change in contour of fetal head due to uterine force with undilated cervix

Overlapping of sutures

May be palpable at birth, lasts 1-2 days

Effacement

The softening and thinning of cervical canal recorded in percentage.

Dilatation

The widening of the external cervical os to 10 cm

Primipara: 1st effacement then dilation

Multipara: Both processes occur at the same time

A point to remember:

If an infant can’t be born vaginally, emphasize to parents that it is the pelvis that is too small, not that the fetal head is too big.

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Uterus

undergoes involution

uterine contraction begins immediately after birth

uterus of a breast-feeding mother may contract more quickly.

area where placenta was implanted is sealed off

organ is reduced to pre-pregnant size (approximately)

fundus of the uterus may be palpated at certain areas/levels at a specified time to determine contraction

Uterine involution

assessed by  measuring fundus by fingerbreadths

uterine involution maybe delayed in several conditions

intermittent contractions enhance involution

involution will occur most dependably if a woman is well nourished & who ambulates early

Nursing Consideration

Position the patient in supine position and assess for contour striae & diastasis; measure width & length in fingerbreadths

Uterus is firm/contracted, uterine atony if relaxed

At a specific location

Uterus is in midline

Presence of after pains maybe normal

Important points to consider:

the 1st hour after birth is potentially the most dangerous

ask the patient to empty bladder

Menstruation

6 weeks after birth in non-nursing moms

24 weeks in nursing moms

Breasts

this is where lactation begins

There are 2 hormones involved:

1. Prolactin - stimulates milk production

2. Oxytocin - initiates let-down reflex with milk ejection as the baby suckles

Point to remember:

Women may ovulate without menstruating, so breastfeeding should not be considered a form of birth control