PRENATAL

ASSESSMENT & CARE

MA. RONELA PAGLINAWAN-MENDOZA, RN, MAN

LEARNING OBJECTIVES
 TOPICS OUTLINE

I. PRENATAL CHECK UP
1. Health History 1. Estimates of pregnancy
A. Past history a. Naegele’s Rule
b. McDonald’s Rule
B. Present history
c. Johnson’s Rule
C. Biographical data d. Bartholomew’s Rule
D.Menstrual history e. Haase’s Rule
E. Current pregnancy (EDD,AOG) f. Quickening

F. OB score / TPAL score 2. Common teratogens

G. OB Gynecologic history and their effects
H.Medical History
I. Nutritional status
REASONS FOR ASSESSMENT

➢ Establish baseline of present health

➢ Determine gestational age of fetus
➢ Monitor fetal development and maternal well-being
➢ Identify women at risk for complications
➢ Minimize risk of possible complications by anticipating
and preventing problems before they occur
➢ Provide education about pregnancy, lactation, and
newborn care
 SCHEDULE OF CLINIC VISIT

❑From first visit to 28 weeks: Every four weeks

❑From 32 weeks to 36 weeks: Every two weeks
❑From 36 weeks until delivery: Every week
COMPONENTS OF PRENATAL VISIT
COMPONENTS OF THE HEALTH HISTORY

Demographic data Partner’s history

Personal information - Age
Name, Address, Age, Civil Genetic or medical
Status, Occupation, disorders
religion, economic status, Alcohol or drug use
and educational level
 Nutritional Status/Diet
practices
 History of emotional or
psychiatric disorders
COMPONENTS OF THE HEALTH HISTORY
 Family Medical History
History of multiple births,
Present Medical
congenital diseases, or Status
deformities  Use of prescription and
nonprescription drugs
Significant medical  Use of alcohol, tobacco, or
problems illegal drugs
 Medical History/History of  Conditions that could
Past Illnesses negatively affect pregnancy
Childhood diseases  Presence of disease, such as
diabetes or cardiac disease
Surgical procedures
Medical problems
COMPONENTS OF THE HEALTH HISTORY

Gynecologic History
Menarche
Length of menstrual cycle
Duration of menstrual flow
History of dysmenorrhea
Gynecologic surgeries
Contraceptive use
Presence of stress incontinence
COMPONENTS OF THE HEALTH HISTORY
OBSTETRIC HISTORY
A. Gravidity: number of pregnancies regardless
of duration and outcomes, including the present
pregnancy
Gravida 1 (G) – pregnant for the first time; a
primigravida had one pregnancy
Multigravida – with two or more
pregnancies
Grand Multigravida – 6 or more pregnancies
Nulligravida – woman who is not pregnant
now and has never been pregnant
COMPONENTS OF THE HEALTH HISTORY
 OBSTETRIC HISTORY
 B. Parity: number of pregnancies carried to period of
viability whether born dead or alive at birth (twins
considered as one parity).
Nullipara – a woman who has not carried a pregnancy
beyond 20 weeks or beyond the period of abortion.
Primipara – a woman who has once delivered a fetus or
fetuses who reached the stage of viability.
Multipara – a woman who has completed two or more
pregnancies to the stage of viability.
Grand multipara – a woman who has had 6 or more viable
deliveries, whether the fetuses were alive or dead.
COMPONENTS OF THE HEALTH HISTORY

C. OB SCORE - GTPALM Score:

 G (gravida) number of pregnancies
 T (term) number of full-term infants born (infants
born at 37 weeks or after)
 P (preterm) number of preterm infants born (infants
born more than 20weeks but less than 37 weeks)
 A (abortion) number of spontaneous miscarriages or
therapeutic abortions
 L (living) number of living children
 M (multiple) Multiple pregnancies
ESTIMATION OF GESTATIONAL AGE

1. Naegele’s Rule – used to determine the expected date

of delivery (EDD) by determining the LMP of the mother.

JUNE 20, 2007

ESTIMATION OF GESTATIONAL AGE

2. McDonald’s Rule - determines age of gestation (AOG)

by measuring the fundic height (FH) from the fundus to
the symphysis pubis (in cm.)

Formula:
Length of fundus in cm x 8/7 = AOG in weeks
Length of fundus in cm x 2/7 = AOG in months
ESTIMATION OF GESTATIONAL AGE

3. Bartholomew's Rule - estimates AOG

by the relative position of the uterus in
the abdominal cavity.
❖ 3 months – just above the symphysis
pubis.
❖ 4 months – midway between
symphysis pubis and umbilicus.
❖ 5 months – at the level of the
umbilicus.
❖ 9 months – just below the xyphoid
process.
❖ 10 months – level at 8 months due to
lightening
ESTIMATION OF GESTATIONAL AGE

4. Johnson’s Rule – estimate

the fetal weight in grams.
 Needs fundic height measure
in cm.

 Formula:
If unengaged: EFW in g =
[FH – 12] x 155
If engaged: EFW in g =
[FH – 11] x 155
ESTIMATION OF GESTATIONAL AGE

5. Haase’s Rule – to determine the length of the fetus in

cm.

▪ First half of pregnancy (1-5 months): month2

▪ Second half of pregnancy (6-10 months): month x 5
COMPONENTS OF THE HEALTH HISTORY

Past Pregnancies:
Method of Delivery
Normal spontaneous vaginal delivery (NSVD)
Cesarean section (CS)
Indication for past CS
Where:
At home?
In the Hospital?
Risk involved:
Prematurity?
Toxemia?
COMPONENTS OF THE HEALTH HISTORY
 Current Pregnancy
First day of last menses
Abnormal symptoms
Attitude toward pregnancy
Maternal Attitude and Reaction towards Pregnancy
Is this a planned or wanted pregnancy?
What support persons/systems are available for
her?
What are her expectations about the pregnancy,
labor, puerperium, and the baby?
What are her plans for prenatal care, labor, delivery,
puerperium, and baby?
PREVENTING FETAL EXPOSURE TO TERATOGENS

 A teratogen is any factor, chemical or physical, that

adversely affects the fertilized ovum, embryo, or fetus.

❖ Lead and mercury, for example, attack and disable

nervous tissue.
❖ Thalidomide, a drug once used to relieve nausea in
pregnancy, causes limb defects.
❖ Tetracycline, a common antibiotic, causes tooth enamel
deficiencies and, possibly, long-bone deformities.
❖ The rubella virus can affect many organs: the eyes, ears,
heart, and brain are the four most commonly attacked.
COMMON TERATOGENS & THEIR EFFECTS
❑ TERATOGENIC MATERNAL INFECTIONS and other VIRAL
DISEASES
 for toxoplasmosis, rubella, cytomegalovirus, and herpes simplex
virus. Some laboratories spell the test as TORSCH to show that
it includes syphilis. Some sources identify the O with “other
infections,” which could include hepatitis B virus (HBV) and
human immunodeficiency virus (HIV)
Toxoplasmosis, Rubella, Cytomegalovirus, Herpes Simplex
Virus (Genital Herpes Infection), Lyme disease
 Infections That Cause Illness at Birth. Several infections are not
teratogenic to a fetus during pregnancy but are harmful if they are
present at the time of birth. Gonorrhea, candidiasis, Chlamydia,
Streptococcus B, and hepatitis B infections are examples of these.
COMMON TERATOGENS & THEIR EFFECTS
❑ TERATOGENIC VACCINES - vaccines, such as measles, HPV,
mumps, rubella, and poliomyelitis (Sabin type), are contraindicated
during pregnancy because they may transmit the viral infection to a
fetus
❑ TERATOGENIC DRUGS –Thalidomide, Minoxidil, Valproic Acid,
Narcotics ( meperidine and heroin) Cocaine, marijuana
❑ ALCOHOL - a high incidence of congenital deformities and
cognitive impairment. fetal alcohol syndrome (FAS) not only is
small for gestational age but can be cognitively challenged
❑ CIGARETTES - is associated with infertility in women, fetal growth
restriction, stillborn after birth, may be at greater risk than others for
sudden infant death syndrome. Low birth weight in infants of
smoking mothers results from vasoconstriction of the uterine
vessels, an effect of nicotine.
COMMON TERATOGENS & THEIR EFFECTS
COMMON TERATOGENS & THEIR EFFECTS

❑ ENVIRONMENTAL TERATOGENS
❑ METAL & CHEMICAL HAZARDS – pesticides and
carbon monoxide, arsenic and mercury, lead
❑ RADIATION – increased risk of cancer in children who
are exposed to radiation in utero
❑ HYPERTHERMIA/HYPOTHERMIA
❑ MATERNAL STRESS
ASSESSING FETAL &
MATERNAL HEALTH

Laboratory / Diagnostic Exams

LEARNING OBJECTIVES

1) At the end of the lecture-discussion, the

students will be able to explain the following:
a. physical findings in pregnant mothers
b. laboratory and diagnostic tests done in
pregnant mothers
c. Danger signs of pregnancy
PRENATAL CARE

❑ A planned program of medical evaluation and

management, observation and education of the
pregnant woman directed toward making
pregnancy, labor, delivery and the post-partum
recovery, a safe and satisfying experience
❑ Include support person/s in the pre-natal visit

NO PRE-NATAL CARE
 Associated with pre-maturity
 Associated with maternal complications
PRENATAL CARE
▪ Begins during childhood
▪ Balanced nutrition with adequate intake of calcium
and vitamin D
▪ Healthy daily diet
▪ Adequate immunizations (rubella)
▪ Safe sex
▪ Regular pelvic examination
▪ Healthy lifestyle
PRENATAL CARE

Purposes
▪ Establish a baseline of present health
▪ Determine the AOG
▪ Monitor fetal development
▪ Identify risk for complications
▪ Minimize the risk for possible complications
▪ Provide education about pregnancy and possible
dangers and complications
FIRST PRENATAL VISIT

▪ Extensive health history

▪ Complete physical examination
▪ Pelvic examination
▪ Pelvic measurement
▪ Laboratory assessment
FREQUENCY OF CHECK UP

 1-6 mos. Once a month

 7-8 mos. 2X a month
 9 mos. Once a week
 1st AP check-up= upon her 1st trimester

Quality Prenatal Care=

 Complete AP-4 AP visit with TT injection + Dental check-up
 Fe SO4- given at 4-5th month of pregnancy up to 2 mos.
Postpartum
TRIMESTERS OF PREGNANCY
A. First Trimester: period of rapid organogenesis;
teratogens like alcohol, drugs, virus, and radiation are
highly damaging.

B. Second Trimester: most comfortable for the mother;

with continued growth of the fetus.

C. Third Trimester: with rapid deposition of fats, iron and

calcium; the period of most rapid fetal growth
PRENATAL ASSESSMENT

1. Interviewing the patient regarding her general

well-being and any concerns or complaints.
2. Weighing
3. Blood pressure assessment
4.Urinalysis for protein and glucose.
5. Abdominal palpation after 24 weeks.
6. Rectal or vaginal examination
PRENATAL ASSESSMENT
A. Physical Examination
– a review of system is
indicated, using
inspection, palpation,
percussion, auscultation
Note: include inspection
of the teeth because
they are common foci of
infection.
PHYSICAL ASSESSMENT
❑ Ears
❑ Head and Scalp
✓ Hair tends to grow faster ✓ Nasal stuffiness results in
during pregnancy. blockage of eustachian tube.
✓ Excess hair dryness. ❑ Mouth and Teeth
❑ Eyes ✓ Normal to find swollen gums
✓ Pale conjunctiva. (Epulis)
✓ Edema of the eyelids ✓ Cracked corners of the
accompanied by visual mouth
disturbances. ✓ Dental carries should be
❑ Nose
treated during pregnancy.
✓ Normal nasal congestion
occurs as a result of estrogen ✓ Major dental operation
stimulation. should be postponed until
the postpartum period.
PHYSICAL ASSESSMENT
❑ Neck ❑ Skin
✓ Slight thyroid enlargement. ✓ Linea nigra, ,mask of
❑ Breast pregnancy, spider nevi,
palmar erythema.
✓ Enlargement of the breast ✓ Pallor, jaundice, rashes
with wider and darker areola, and skin lesions are
prominent veins abnormal findings.
✓ Breast masses, nodules, ❑ Back
dimpling of the skin and ✓ Exaggerated lumbar
bloody nipple discharge are curve late in pregnancy
abnormal findings. occurs as a result of the
✓ Presence of Colostrum. shifting of the pregnant
woman’s center of gravity
PHYSICAL ASSESSMENT

❑ Extremities
❑Rectum
✓ Ankle swelling
✓ Presence of hemorrhoids
✓ Leg edema
✓ Waddling Gait
✓ Edema of upper extremities, face and
hands are danger signs.
PHYSICAL ASSESSMENT

Abdominal Exam
Fundic Height
› Measured from the superior border of the symphysis pubis to the
superior aspect of the fundus
› Can estimate AOG from 12 – 28 weeks

Leopold’s Maneuver
› Fetal outline and position determined after the 28th week

Fetal Heart Beat

› 120 – 160 bpm
LEOPOLD’S MANEUVER

❑It is a systematic way to evaluate the presentation,

position and attitude of the fetus.
❑PURPOSES
✓ To determine the presentation, position and attitude of
the fetus;
✓ To estimate the fetal size;
✓ To locate fetal parts.
LEOPOLD’S MANEUVER
❑ Preparation:
1. Instruct woman to empty her bladder first.
2. Place woman in dorsal recumbent position, supine with knees
flexed to relax abdominal muscles. Place a small pillow under the
head for comfort.
3. Drape properly to maintain privacy.
4. Explain procedure to the patient.
5. Warms hands by rubbing together. (Cold hands can stimulate
uterine contractions).
6. Use the palm for palpation not the fingers.
LEOPOLD’S MANEUVER
LEOPOLD’S MANEUVER

❑ FIRST MANEUVER (
FUNDAL GRIP)
❑ To determine what
part of the fetus lies in
the upper part of the
uterus.
LEOPOLD’S MANEUVER
Maneuver Purpose Procedure Findings
First To determine Using both If the fetus is
Maneuver: fetal part lying hands feel for cephalic:
Fundal Grip in the fundus the fetal part Head – round,
lying in the smooth with
To determine fundus transverse groove of
Presentation the neck.
If the fetus is breech:
Buttocks – soft and
angular.
LEOPOLD’S MANEUVER

❑2nd MANEUVER (
UMBILICAL GRIP)
❑ To determine which side of
the uterus is fetal back is
located
❑ NOTE:
 Fetal Spine/Back – smooth,
curved resistant plane.
 Fetal extremities ( knees &
elbow ) – smaller lumps &
irregular parts
LEOPOLD’S MANEUVER
Second To identify One Hand is used to Small fetal parts
Maneuver: location of steady the uterus on feel nodular
Umbilical fetal back one side of the with numerous
Grip abdomen, while the angular
To determine other hand moves nodulations.
position slightly on a circular Fetal back feels
motion from top to smooth, hard
the lower segment of like a resistant
the uterus to feel for plane.
the fetal back and
small parts. Use gentle
but deep pressure.
LEOPOLD’S MANEUVER
❑ 3RD MANEUVER ( PAWLICK’S
GRIP)
❑ To determine engagement of
the presenting part
Note:
❑ Engagement
❑ fetus is immovable
❑ Ballottement
❑ fetus movable/bounces
LEOPOLD’S MANEUVER
Third Maneuver: To determine Using thumb and The presenting
Pawlick’s Grip engagement index finger, grasp part is engaged
of the the lower portion if it is not
presenting of the abdomen movable.
part above the It is not yet
symphisis pubis, engaged if it is
press in slightly still movable
and make gentle
movements from
side to side.
LEOPOLD’S MANEUVER
4TH MANEUVER ( PELVIC
GRIP)

To determine degree of

flexion of fetal head.
To determine attitude or
habitus
LEOPOLD’S MANEUVER
Fourth To Facing foot If descended deeply, only a
Maneuver: determine part of the small portion of the head will
Pelvic Grip degree of women, be palpated. If cephalic,
flexion of palpate fetal brow of the baby is on the
fetal head. head pressing same side of the fetal part,
To downward the head is flexed.
determine about 2 If the head is extended, brow
attitude or inches above is on the same side of the
habitus the inguinal fetal back.
ligament. Use
both hands
LEOPOLD’S MANEUVER

❑ Patient should empty her bladder so that fetal

contour will not be obscured.
❑ Examiner’s hand should be warm to prevent
tightening of abdominal muscles.
❑ Explain the procedure to the patient
❑ Provide privacy
❑ Position patient in dorsal recumbent or supine.
❑ Apply gentle but firm motions.
LEOPOLD’S MANEUVER
 ULTRASONOGRAPHY
• Ultrasonography measures
4. To establish sex/ gender if the penis is
the response to sound waves revealed.
against solid objects. 5. To establish the presentation and
 Purpose: position of the fetus.
1. To diagnose pregnancy as early as 6 6. To predict maturity by measurement of
weeks gestation.
the bi-parietal diameter of the head.
2. To confirm the presence, size, and
location of the placenta and 7. Used to discover the presence of
amniotic fluid. intrauterine device, hydramnios,
3. To establish that a fetus is growing abdominal pregnancy, placenta previa,
and has no gross anomalies such as premature separation of the placenta, co-
hydrocephalus, anencephaly, or existing intrauterine tumors, multiple
spinal cord, heart, kidney and
pregnancies, genetic abnormalities (Down
bladder defects.
syndrome), fetal anomalies, fetal death,
retained placenta fragments.
ULTRASONOGRAPHY
TRANSABDOMINAL & TRANSVAGINAL ULTRASONOGRAPHY

TRANSVAGINAL
TRANSABDOMINAL
 PELVIC EXAMINATION

❑Internal Examination
(IE)
❑ Ballottement
❑Papanicolaou smear
(Pap smear)
 INTERNAL EXAMINATION/VAGINAL EXAMINATION

❑ Internal Examination or
Vaginal Examination
 Purpose:
 During the first clinic visit,
IE is used to confirm
pregnancy and gestation.
 After 34 weeks, IE is
performed to assess
consistency of cervix,
length and dilatation,
Fetal presenting part,
body architecture of the
pelvis.
INTERNAL EXAMINATION/VAGINAL EXAMINATION
Pelvic Exam
Equipment necessary
Pelvic Exam
 Examining table
 Examining light  External genitalia
 Stool
 Clean examining glove
 Speculum exam
 Lubricant for IE  Internal exam
 Speculum (water as
 Bimanual exam
lubricant)
 Pap smear equipment  Examine pelvic
 Glass slide, culture tube organs
(bottle), spatula, 2 or 3 sterile
cotton-tipped applicators
 Rectovaginal
exam
PATIENT PREPARATION FOR INTERNAL EXAMINATION

1. Provide explanation. 7. Instruct woman not to:

2. Let woman empty her  Hold or squeeze your hands.
bladder first.  Hold her breath
 Close eyes tightly
3. Provide good lighting.
 Contract perineal muscles.
4. Place woman in lithotomy
position with buttocks 8. Explain the procedure. It may
extended slightly beyond be slightly uncomfortable.
examining table. 9. After the procedure, provide
5. Drape properly tissue to wipe perineum of
lubricant.
6. Let support person stay at
the head of the bed.
 PAPANICOLAU SMEAR/SPECULUM EXAM

This is done to examine the internal genital tract and to

obtain specimen for cytological examination
known as PAP SMEAR
Done to screen for cancerous and precancerous cells of
the cervix
PAPANICOLAU SMEAR/SPECULUM EXAM

❑FREQUENCY OF EXAMINATION

❑A woman should undergo her first Pap test within three

year after her first sexual intercourse or at the age of 18.
❑All women who are sexually active should have a Pap
test every year during the first three years from the first
coitus
PAPANICOLAU SMEAR/SPECULUM EXAM

1. Instruct the woman to avoid 4. Inform the patient that

coitus, douches, tampons, vaginal during the insertion of the
medication, or vaginal sprays for speculum, she may fell some
at least 24 hours before having a pressure or pulling.
Pap test. 5. Instruct patient to breathe
2. Schedule the test not on the deeply and avoid tensing her
time of menstruation. perineal muscles during the
3. Make the patient empty her insertion of the speculum.
bladder before the examination. 6. A small amount of vaginal
bleeding is expected after
this test.
PAPANICOLAU SMEAR/SPECULUM EXAM
❑CLASSIFICATION OF (PAP SMEAR) FINDINGS

❑Class 1 – absence of a typical or abnormal cells (normal)

❑Class 2 – atypical cytology but no evidence of
malignancy
❑Class 3 – cytology suggestive of malignancy
❑Class 4 – cytology strongly suggestive of malignancy
❑Class 5 – conclusive for malignancy
VITAL SIGNS

❑Blood Pressure
The most important vital
sign that should be
monitored every clinic
visit.
No significant change in
blood pressure during
gestation.
VITAL SIGNS

Roll-over Test
used to screen patients at
risk for developing PIH.
also know as Supine
Pressor Test
majority of women tested
(+) to this test develop
PIH.
VITAL SIGNS

❑Mean Arterial Pressure

❑Pulse Rate
(MAP)  Pulse rate increases by
 Take blood pressure and compute about 10 beats per
the MAP using this formula: minute.
 1/3 (systolic + (2 x diastolic) = MAP  Arrhythmias or
 The result is positive if the findings palpitations are normal
is more than 85 mmHg. during pregnancy as long
as it s not accompanied
by dizziness.
VITAL SIGNS

❑Respiratory Rate ❑Temperature

❑Increased in depth, no ❑There is a slight elevation of
significant change in rate. temperature early in
❑Shortness of breath and pregnancy
dyspnea late in pregnancy
is common.
BLOOD STUDIES
complete blood count,  indirect Coombs’ test
(determination if Rh antibodies
genetic screen are present in an Rh-negative
serologic test for woman).
syphilis (VDRL or rapid  Antibody titers for rubella and
plasma reagin test) hepatitis B (HBsAg).
Blood typing (including  HIV screening
Rh factor  TB screening
Maternal serum for  glucose loading or tolerance
test
alpha fetoprotein (AFP)
(MSAFP)
BLOOD STUDIES
 Complete Blood Count ❑Leukocyte Count
(CBC)
❑ Used primarily as a screen to rule out
 done at initial clinic visit leukemia and possible infection.
and repeated at 28- 32 ❑ Nonpregnant values are 5,000 –
weeks to detect 10,000 but may reach 16,000 during
pregnancy
ANEMIA.
 Hgb and Hct levels fall,
resulting in
pseudoanemia.
BLOOD STUDIES

❑Blood Type ❑ Rh antibody screen

❑ Check for ABO incompatibility. ❑ Serologic Test
❑ Rh Factor ❑ Maternal serum AFP (16 – 18
❑ Check for Rh incompatibility. weeks)
❑Coombs' test is done to ❑ Rubella antibody titer
detect for the presence of ❑ HBsAg (last trimester)
antibodies in maternal ❑ Screen for diabetes
blood. ❑ HIV and chlamydia screening
HIV SCREENING TEST

 HIV Screen  HIV screening is

 Woman who belongs to recommended for the
the high-risk group need women:
to undergo HIV screening  1. Who are intravenous drug
done by ELIZA. (IV) users.
 2. With multiple sexual
 Western blot test – done if partners.
the result of ELIZA test is  3. With sexual partners who
positive. are HIV positive or who belong
 Zidovudine (AZT) drug of to the high-risk group.
choice to for HIV during  4. Who received blood
pregnancy. transfusions during 1977 to
1985.
TUBERCULOSIS SCREENING TEST

 purified protein derivative

(PPD) tuberculin test/Mantoux
test
 chest radiograph/XRAY
URINALYSIS/URINE EXAMINATION

❑Heat and acetic acid test

– to determine
albuminuria. Any sign of
albumin in the urine
should be reported
immediately because it is
a serious sign of toxemia
URINALYSIS/URINE EXAMINATION

❑ Benedict’s test for glycosuria – a sign of possible

gestational diabetes. Specimen should be taken
before breakfast to avoid false positive result. Should
not be more than +1 sugar.
URINALYSIS/URINE EXAMINATION

▪ Albuminuria
▪ Glycosuria
▪ Pyuria
Determination of pyuria – Urinary tract infection has
been found to be a common cause of premature
delivery
ORAL GLUCOSE TOLERANCE TEST (OGTT, OGCT)
❑ OGTT, OGCT (50g or 100g)
Indicated if the woman has the ff:
✓ Hx of previous fetal loss
✓ FHx of diabetes
✓ Hx of LGA baby (9lbs or more)
✓ Obese or glycosuria
✓ Done toward the end of the 1st trimester
✓ To rule out GDM
ORAL GLUCOSE TOLERANCE TEST
▪ if Screen for diabetes
▪ History of unexplained fetal loss
▪ Family history of diabetes
▪ Babies who were LGA
▪ Obese
▪ Glycosuria
 24 – 28th week AOG
 50gm 1 hr OGTT
 <140 mg/dL
DANGER SIGNS OF PREGNANCY
1.Vaginal Bleeding
 may start as a slight spotting
 1st trimester – possibly related to abortion
 3rd trimester – may indicate placenta
previa
2.Persistent vomiting
 1-2x/day is considered normal
 Vomiting past 12 weeks = excessive
vomiting (hyperemesis gravidarum)
3.Chills and fever
 May indicate Gastroenteritis or
intrauterine infection
 Needs further evaluation
DANGER SIGNS OF PREGNANCY

4. Sudden passage of watery discharge from the

vagina
May be due to preterm rupture (after 20 weeks but
before 37 weeks of gestation)
May also be due to PROM (after 37 weeks but
before labor)
Complication of PROM : prolapsed umbilical cord ;
may affect fetal oxygenation if the cord is
compressed by the fetal head
DANGER SIGNS OF PREGNANCY
5. Abdominal or chest pain
❑ A normal uterus expands painlessly
❖ Crampy low abdominal pain with or without bleeding = abortion
❖ LQ pain, sudden, sharp, severe, unilateral radiating to the shoulders
❖ (Kehr’s sign) = Ectopic pregnancy
❖ Hard board-like, painful = abruption placenta
❖ Painless vaginal bleeding (3rd tri) = placenta previa
❖ Chest pain = pulmonary embolus secondary to thrombophlebitis

6. Severe persistent headache, dizziness, double or blurring of vision

❑ Less than 20 weeks = H-mole
❑ After 20 weeks = pre eclampsia/ eclampsia
DANGER SIGNS OF PREGNANCY
7. Swelling of the hands and face
 A sign of generalized edema
 Edema of the legs in late PM and/or due to prolonged standing is
normal
 May be associated with pre eclampsia

8. Sudden and marked change in the character and frequency

of fetal movements
 May indicate fetal distress
 4-10 movements/hr is normal
DANGER SIGNS OF PREGNANCY
SUBSEQUENT PRENATAL CARE
FREQUENCY OF VISIT

 Every 4 weeks until the 28th week AOG

 Every 2 weeks until the 36th week AOG
 Every week thereafter

 WHO recommendation --- 5 pre-natal visits

HIGH-RISK PREGNANCY
 SUBSEQUENT PRENATAL CARE

INTERVAL HISTORY

▪ History since the last visit

▪ Symptoms: n/v, h/a, bleeding, dysuria, fluid from vagina,
etc
▪ Fetal movement
▪ Diet and sleep
SUBSEQUENT PRENATAL CARE
PHYSICAL EXAMINATION
Maternal evaluation
 BP, note changes
 Weight, note changes
 Fundic height
 Abdominal examination with LM
 Leg edema
 Vaginal examination only if indicated
 At term, should be done weekly
 Should not be done if with history of bleeding unless in a double set-up
SUBSEQUENT PRENATAL CARE
PHYSICAL EXAMINATION
Fetal evaluation
Fetal heart rate
Size of fetus, note changes
Amount of amniotic fluid
Presenting part and station (late in pregnancy)
Fetal activity
SUBSEQUENT PRENATAL CARE

LABORATORY EXAM
Most tests are not
repeated if initial results
were normal
CBC should be repeated
at about 28 – 32 weeks