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Prenatal care is that health care given to a pregnant woman and to the developing fetus until the time of delivery.
The purpose of prenatal care is to:
Practitioners of prenatal care need to be aware of the possibility of domestic abuse, since such violence may begin with a pregnancy. About half of the women who are abused prior to becoming pregnant will continue to be abused during the pregnancy. Questions about abuse should be included at the first prenatal visit, and periodically thereafter if suspicion of it arises.
The prenatal period lasts about 38 weeks from conception to delivery, or 40 weeks from the last menstrual period (LMP). It may also be referred to as the antenatal period. While some women come for their first prenatal visit shortly after missing a menstrual period, others may not come for prenatal care until later.
The first prenatal visit is usually the longest, as it includes a complete health history, physical examination (including pelvic and bimanual exams), and blood
The pregnancy is confirmed at the first prenatal visit. A urine or blood test may be done as well as a physical examination. A woman may have taken a home pregnancy test after a missed period and may already be experiencing some nausea, vomiting, or breast tenderness. Practitioners should assess the woman's feelings about the pregnancy and assist in appropriate referrals if she needs further counseling.
The complete health history should record the following information:
|Prenatal visit schedule recommended by the U.S. Public Health Service|
|First pregnancy||Second or later pregnancy|
|SOURCE: Public Health Service Expert Panel on the Content of Prenatal Care, Dept. of Health and Human Services, 1989.|
|First visit: 6–8 weeks||First visit: 6–8 weeks|
|Second visit: Within 4 wks of first||Second visit: 14–16 weeks|
|Third visit: 14–16 weeks||Third visit: 24–28 weeks|
|Fourth visit: 24–28 weeks||Fourth visit: 32 weeks|
|Fifth visit: 32 weeks||Fifth visit: 35 weeks|
|Sixth visit: 36 weeks||Sixth visit: 39 weeks|
|Seventh visit: 38 weeks||Seventh visit: 41 weeks|
|Eighth visit: 40 weeks|
|Ninth visit: 41 weeks|
|Important points in prenatal care|
|Objective data||Emotional assessment||Laboratory|
|SOURCE: Wheeler, L. Nurse-Midwifery Handbook: A Practical Guide to Prenatal and Postpartum Care. Philadelphia: Lippincott-Raven Pub., 1997.|
|First visit||Accurate blood pressure (BP)
Cervical length and dilation
Body Mass Index (BMI)
|Feelings about this pregnancy/previous birth/losses
Need for referral: counseling, food, shelter, genetics, etc.
|Consider: HIV, PPD, sonogram, glucose screen|
|16 to 19 weeks||Amniocentesis|
|20 weeks||Fetal heart tones with fetoscope
|Stressors and body image|
|24 to 26 weeks||Cervix check if history of pre-term labor or if first baby||Recurrent or vivid dreams; fears|
|28 weeks||Weight gain
|Stressors and body image||Glu screen
Rh immune globulin
|36 weeks||Presentation||Fears about labor||Consider repeating: Hct., GC and chlamydia, RPR, HIV, HbsAg
Schedule version if breech
Normal physical changes to expect during pregnancy should be discussed. The pregnant woman should also be given the emergency number to call when the health facility is closed, along with guidelines about when it is appropriate to call. Teaching about the use of over-thecounter medications should be done, as many people are not aware that nonprescription drugs can be harmful to the developing fetus. Before leaving from the first prenatal visit, the next appointment should be scheduled, to encourage ongoing care.
Subsequent prenatal visits are considerably shorter, unless complications arise. A routine visit includes a urine check for protein, glucose, and possibly ketones; a weight and blood-pressure check; and measurement of fundal height. At each visit the woman should be asked if she is experiencing any of the common discomforts of pregnancy, such as ankle edema (swelling), leg cramps, Braxton-Hicks contractions, fatigue, backache, nausea or vomiting, constipation, or shortness of breath. In the first trimester, and again toward the end of pregnancy, the uterus applies pressure on the bladder, possibly resulting in the need for frequent urination. If frequency is accompanied by burning or pain with urination, a urinary tract infection should be ruled out.
While nausea and vomiting are common until the fourth or fifth month of pregnancy, excessive vomiting can result in dehydration and electrolyte imbalance. Sometimes hospitalization is required. The new mother should also be educated about signs that might indicate a developing problem, such as abdominal pain (perhaps
An opportunity should be provided to answer any questions the woman might have. Attendance at childbirth and/or parenting classes, and access to classes for older siblings, should be discussed. The pregnant woman should also be assessed for signs of depression. As the pregnancy progresses, lying supine can cause the uterus to compress the vena cava, impeding blood flow to the heart. This may be experienced as an irregular heart rate or a feeling of anxiety. Lying on the left side resolves this problem.
Pregnant women should be encouraged to eat a wide variety of nutritious foods. Women whose prepregnancy weight is within an appropriate range for height should expect to gain about 25 to 35 pounds over the course of the pregnancy. Those who are overweight should gain less, but not try to diet while pregnant. Pica, or the desire to eat nonfood substances, may not cause harm to the fetus if the substances themselves are not harmful and the woman is otherwise eating a balanced diet. Questions to assess for pica should be part of routine visits. A woman's financial situation can affect her ability to purchase nutritious foods. This need should be assessed at the first visit so that an appropriate referral can be made for food stamps or other assistance programs. The use of megavitamins should be evaluated, as high doses of fat-soluble vitamins can be harmful. Intake of high doses of vitamin A is associated with birth defects.
At 10 to 18 weeks, genetic counseling may be provided for women with a family history of congenital, chromosomal, or neural-tube anomalies, or for women above age 35. Chorionic villi sampling (CVS) may be done between 10 and 12 weeks, while amniocentesis may be performed between 14 and 18 weeks. Ultrasound may be done between 12 and 24 weeks to confirm dating of the pregnancy or to check fetal anatomy.
A triple marker screen test that evaluates maternal serum alpha-fetoprotein, human chorionic gonadotropin (hCG), and unconjugated estriol levels is usually run on a blood sample between 16 and 20 weeks to screen for neural-tube defects. Inadequate intake of folic acid is associated with such neural-tube defects as spina bifida. Elevated levels of alpha fetoprotein may indicate a neural-tube defect, but can also be due to a multiple pregnancy, inaccurate dates, or fetal death. The test can also indicate if the fetus has Down's syndrome. As with other laboratory tests, false positives can occur.
At 20 to 22 weeks, women should be aware of the danger of premature rupture of the membranes and preterm labor. Fundal height should be at the umbilicus.
Screening for gestational diabetes is done around 26 to 28 weeks. The first screening test does not require fasting, and blood is drawn once, an hour after a drink containing 50 gm of glucose is ingested. If the result is abnormal in any way, a three-hour glucose tolerance test (GTT) will be administered. This test is usually done in the morning, after the woman has fasted for eight hours. A sample for the FBS (fasting blood sugar) test is drawn, glucose is given, and blood is then drawn hourly over the next three hours. Babies of mothers with gestational diabetes are at risk of excessive intrauterine growth, and blood sugar abnormalities after birth. While gestational diabetes (GDM) usually resolves when the pregnancy terminates, women with GDM are at increased risk—about 60%—of developing diabetes within the next 16 years.
From 28 weeks to 34 weeks onward, fetal presentation (position) will be checked at each visit.
After 36 weeks the physician may choose to conduct a sterile internal exam to evaluate the condition of the cervix for labor and delivery.
From 40 to 42 weeks fetal well-being and the amount of amniotic fluid may be monitored more closely. Too little or too much may indicate problems. Induction of labor will be considered.
Author Info: Esther Csapo Rastegari R.N., B.S.N., Ed.M., The Gale Group Inc., Gale, Detroit, Gale Encyclopedia of Nursing and Allied Health, 2002
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