Prenatal care or antenatal care refers to the health care given to a woman

and her family during pregnancy. The primary goal of prenatal care is to provide
maximum health to expectant mothers and their baby.

Goals of prenatal care:

1. To ensure a healthy and uncomplicated pregnancy and the delivery of a

healthy infant.

2. To identify and treat high risk conditions.

3. To individualize patient care.

4. To assist the patient for her preparation for labor, delivery, and puerperium.

5. To screen and identify risk factors or diseases that may affect the mother or
the infant’s health and life

6. To reinforce healthy habits to the woman and her family.

Definition of terms:

Gravida. Refers to a pregnant woman. The number of pregnancies a woman has had
regardless of the outcome of pregnancy.

Nulligravida. A woman who had never been pregnant.

Primigravida. A woman pregnant for the first time.

Multigravida. A woman who has had two or more pregnancies.

Para. The number of pregnancies that reached viability or the number of

pregnancies that reached 20 weeks or more, or number of fetus delivered with birth
weight of 500 grams or more.

Nullipara. A woman who has never delivered a fetus that reached the age of
viability.

Primipara. A woman who has completed one pregnancy to viability.

Multipara. A woman who has completed two or more pregnancies to viability.

Schedule of clinic visit

Prenatal visits clinic visits should begin as soon as possible after the first missed
period. Subsequent clinic visits for normal pregnancy are scheduled as follows:

From first visit to 32 weeks – every 4 weeks

From 32 weeks to 36 weeks – every 2 weeks

From 36 weeks until delivery – every week

The desirable number of clinic visits according to WHO is 5 visits during the entire
length of pregnancy and the minimum is 3 visits.

First clinic visit

The initial antepartal clinic visit is a time to obtain baseline data through interview,
laboratory tests and complete physical examination. Based on the assessment
findings, the nurse should identify risk conditions or factors that increase the
possibility of complications for the mother and the fetus during pregnancy.
Activities on initial clinic visit consist of:

• Hx taking

• Complete PE

• Lab tests

• Fetal assessment

• Health teachings

Subsequent visits

A. Maternal assessment

1. BP

2. Weight

3. Nutrition, discomforts, S/S, danger signals

4. Other problems and concerns of the woman

B. Fetal assessment

1. Fetal heart rate

2. Quickening

3. Fundic height

4. Leopold’s maneuver

5. Vaginal examination

C. Health teachings

1. Normal S/S
 2. Minor discomforts, prevention and management

3. Danger S/S

4. Nutrition and diet

5. Rest, exercise, and relaxation

6. Avoidance of drugs, alcohol, cigarettes, and too much caffeine

7. Clothing

8. Sexual relations

9. Employment

10.Travel

11.Preparation for the baby’s birth, delivery and puerperium

Hx of past pregnancies

T refers to term births (after 37 weeks gestation)

P refers to premature births

A refers to abortions

L refers to living children

G number of pregnancies irrespective of gestational age

P number of pregnancies that reached viability

Signs of first pregnancy:

• Uterus is tense and firm

• Frenulum is intact

• Labia majora in close apposition

• Vagina is narrow with numerous rugae

• Cervix is soft but do not admit tip of finger until the very end of the
pregnancy

Signs of previous pregnancy:

 • Pendulous and lax abdominal wall

• Abdominal striae

• Labia gapes wider

• Hymen is transformed to myrtiform carunculae

• Cervix admits tip of cervix

• Sites of healed laceration of the cervix can be identified

TT Immunization

Tetanus Toxoid Interval Immunity

TT1 As early as possible during

pregnancy

TT2 One month after TT1 3 years

TT3 6 months after TT2 5 years

TT4 One year after TT3 10 years

TT5 One year after TT4 lifetime

EDC (expected date of confinement)

Naegele’s Rule. Is a standard way of calculating the due date for a pregnancy. It is
named after Franz Karl Naegele (1778-1851), the German obstetrician who
devised the rule.

LMP = 8 May 2007

+1 year = 8 May 2008

-3 months = 8 February 2008
+7 days = 15 February 2008

AOG (age of gestation)

Mc Donald’s Rule

Fundic height(cm) x2/7 = AOG in lunar months

Fundic height(cm) x8/7 = AOG in weeks

Bartolomew’s Rule

12 weeks – level of the symphysis pubis

16 weeks – halfway between the umbilicus and symphysis pubis

20 weeks – level of umbilicus

24 weeks – 2 fingers above the umbilicus

28-30 weeks – halfway between the umbilicus and xiphoid process

32-34 weeks – just below the xiphoid process

36 weeks – level of xiphoid process

40 weeks – at 34 weeks level due to lightening

Other calculations

Johnson’s Rule. To determine the fetal weight

Fundic height(cm) – N x K = fetal weight

K = 155(constant)

N = 12 if engaged

N = 11 if not engaged

Haase’s Rule. To determine the length of fetus

During the first half of pregnancy, square the number of months.

During the second half of pregnancy, multiply the number of months by 5.

Leopold’s Maneuver

Is a systematic way to determine the position of a fetus inside the woman's uterus.
 Maneuver
First maneuver: Fundal
Grip
To determine the fetal
presentation
Second maneuver:
Umblical Grip
to identify the location of
the fetal back
to determine the position
Third maneuver:
Pawlick's Grip
to determine the
engagement of the
presenting part
Procedure
While facing the client,
palpate the client's upper
abdomen with both hands
Still facing the woman, the
nurse palpates the
abdomen with gentle but
also deep pressure using
the palms of the hands.
First the right hand
remains steady on one
side of the abdomen while
the left hand explores the
right side of the woman's
uterus. This is then
repeated using the left
hand.
Using the thumb and the
finger, grasp the lower
portion of the abdomen
above the symphysis
pubis. Press slightly and
make gentle movements
from side to side
Findings
If the nurse feels the head
which is round, smooth,
the fetus is in breech
presentation.
If the nurse feels the
buttocks which is soft and
angular, the fetus is in
cephalic presentation.
Fetal back feels smooth
and hard
Small fetal parts feel
nodular with numerous
angular nodulations.
The presenting part is
engaged if it is not
movable.
It is not yet engaged if it is
movable.
Fourth maneuver: Facing the foot part of the
Pelvic Grip client, palpate fetal head
pressing downward about
To determine the attitude 2inches above the inguinal
ligament
If the cephalic
prominence or the brow of
the baby is on the same
side with the small fetal
parts, the head is flexed

If cephalic prominence is
on the same side of the
fetal back, the head is
extended.

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, bony architechture of the pelvis, anomalies
of the vagina and perineum, including rectocele, cystocele and lesions

Patient preparation:

1. Provide explanation

2. Let the client empty her bladder first

3. Provide good lighting

4. Place the client in lithotomy position with the buttocks extended slightly
beyond examining table

5. Drape properly

6. Instruct the client not to:

• hold her breath

• clench fist

• contract perineal muscles

7. Explain the procedure

8. After the procedure, provide tissue to wipe perineum

 Discomfort of Pregnancy
Nausea and Vomiting

Also knows as morning sickness because it usually occurs in the morning.

Commence 6 weeks after the last menstrual period and disappear s by the end of
the first trimester. The exact cause is not known but it has been attributed to
Human Chorionic Gonadotropin. It may be psychologic in origin: ambivalence or
nonacceptance of pregnany. Most women experience nausea and vomiting in the
morning but it may occur anytime of the day.

Management:

a. Eat dry toast or cracker before rising from the bed.

b. Eat small frequent meals rather than 3 large ones.

Frequent urination

First appears on the first trimester when the enlarging uterus exerts pressure
on the bladder as it rises out of the pelvic cavity. It disappears on the second
trimester when the uterus has become an abdominal organ. Frequency of urination
returns late in pregnancy when the presenting part exerts pressure on the bladder.

Management:

a. Limit fluid intake before bedtime.

b. Kegel exercise to improve tone of muscles that controls urination.

Fatigue

Fatigue on the first trimester is due to the action of progesterone on the

sleep center of the brain. On the second and third trimester, it is thought to be due
to increased metabolic rate and increased weight of the gravid uterus.

Management:

a. Take atleast 8 hours of sleep at night and frequent rest periods during
the day.

b. Avoid standing for long periods, work while seated as much as

possible.

c. Eat a well balanced diet to provide enough energy.

Breast Tenderness and Nipple Irritation

Breast discomfort occurs throughout pregnancy. It is due to alveolar cell

development as stimulated by increase levels of estrogen.

Management:

a. Wash breast with water only, no soaps and alcohol to prevent drying
and irritation.

b. Wear supportive maternity brassiere.

Leukorrhea

High level of estrogen causes hyperactivity of cervical glands throughout

pregnancy.

Management:

a. Proper perineal hygiene, flush perineum with water after each voiding,
no douching is necessary.

b. Use of sanitary pad for excessive vaginal discharge.

Nasal stuffiness

Elevated estrogen levels results in hyperemia of mucous membranes. Occurs

throughout pregnancy.

Management:

a. Avoid allergens and smoke filled rooms.

 b. Normal saline nose drops (1/4 tsp salt in 1 cup water).

c. Breathe steam from pot of boiling water.

Heartburn or Pyrosis

Progesterone slows down gastric motility resulting in reflux of gastric

contents in the lower esophagus. The acidic nature of gastric contents cause
irritation of esophageal mucosa.

Management:

a. Take small meals rather than three large ones.

b. Bend at knees not waist when picking objects from the floor, avoid
lying flat.

Varicose Veins

Varicosities cause largely by hereditary predisposition, advancing age,

prolonged standing and exaggerated by pregnancy. It usually becomes apparent
during the second and third trimester when the uterus is enlarged enough to
impede return blood from the lower extremities.

Management:

Leg Varicosities

a. Periodic rest with elevation of the legs, lie with feet against the wall.

b. Avoid prolonged sitting or standing, constricting garters, knee high

socks.

c. Wear support hose.

d. Apply elastic bandage before getting up in the morning starting at the

distal ends but don’t wrap the toes.

Vulvar Varicosities

a. Rest with pillows under the hips.

b. Modified knee chest position.

Anal Varicosities or hemorrhoids

a. Sim’s position several times a day.

b. Avoid constipation.
 c. Hot sitz bath 15-20 minutes

d. Avoid bearing down.

e. Observe good bowel habits.

f. Use of topically applied anesthetics, use of stool softeners and warm

soaks.

Backache

The major part of the gravid uterus rests on the anterior abdominal wall when
the woman stands altering her center of gravity. In order to maintain her balance,
the woman walks with head and shoulders thrown backwards with the chest and
abdomen forward. This posture results in exaggerated inward curve of the spine
called lordosis. The relation of sacroiliac joints throws greater strain on the
surrounding muscles causing low backache during pregnancy.

Management:

a. Pelvic rocking exercise to relieve low backache.

b. Frequent rest and avoidance of fatigue.

Leg Cramps

Also known as Charley Horse, is thought to be cause by the pressure of the

uterus against the nerve supplying the lower extremities. It may also be due to
fatigue, chilling, insufficient calcium and excessive phosphorus in the diet.

Management:

a. For immediate relief push toe upward while applying pressure on the
knee to straighten the leg.

b. One quart of milk a day to meet the calcium needs or oral calcium
supplements as prescribed by the physician.

c. Exercise regularly but avoid pointing of toes.

Headache

Normal headache of pregnancy is common during the first trimester. Some

cases leads to sinusitis or ocular strain caused by refractive errors. The cause is
unknown. By midpregnancy, these headaches have decreased in severity or are
gone. Headache in the third trimester, especially if frontal and accompanied by
visual disturbances should be investigated as this maybe caused by Pregnancy
Induced Hypertension (PIH).
Promoting Fetal and Maternal Health:

A major role in promoting fetal and maternal health is education. Generally,

a woman who eats well and takes care of her own health during pregnancy

provides a healthy environment of fetal growth and development.

Health Promotion during Pregnancy:

• Daily tub baths or showers are recommended because sweating tends

to increase because a woman excretes waste product for herself and a
fetus.
As pregnancy advances, showering to sponge bathing is recommended
for their safety. During last month of pregnancy do not bath in the tub
• Woman should wear a firm, supportive bra wide straps to spread
weight across shoulders. In halfway of the pregnancy she should buy a
larger
Bra to accommodate increased breast size.
• Colostrum begins to secrete on the 16th week , it may be rightening if
she is not warned, instruct her to wash the breast with clean tap water
( no
Soap because this could be drying:) daily to remove and reduce
infection. If secretion is heavy, place a gauze pad inside the bra
• Brushing teeth evry ater meals. Encourage to see her dentist or
examinations and cleaning.
• Encourage woman to snack on nutritious foods such as fresh fruits and
vegetables like apples, carrots to avoid sugar in mouth and teeth.
• Douching is not allowed because it alters the ph of the vagina leading
to bacterial growth
• Woman should avoid garters, firm girdles, knee-high stockings because
it impedes lower extremity circulation. Comfort and common sense are
The basic rule.
• Coitus is not restricted during pregnancy
• Well nourished women should exercise during pregnancy everyday or
30 minutes. Exercise is important to prevent circulatory stasis in the
lower
Extremities , and offer general feeling of well being. An exercise
program must start with 5 minutes warm-up, 20 minutes active
stimulus and 10 minutes cool down exercises.
• If a woman has trouble falling asleep, drinking a glass o warm milk
may help, relaxation exercises may also be eective. A good sleeping
position is
Sims position with the top leg forward because this puts the weight of
the fetus on the bed, not on the woman and allows good circulation in
the
Lower extremities.. Avoid resting in a supine position because this
would lead to hypotension syndrome because of the pressure of the
expanding
Uterus on the inferior vena cava. And should be avoided not to rest
with her knees sharply bent either when sitting or lying down because
of the
Increased risk of venous stasis.
• WORK:
1. Plan to rest during your break periods rather than running an
errand
2. Get extra rest on weekends or days off.
3. Rest by elevating your legs or lie on your let side during rest period
4. Wear support hose to improve venous return
5. Empty your bladder every two hours to prevent bladder infection.
6. Take extra caution when working around equipment that requires
good balance.
7. Take time to pack nutritious snacks and meals.
8. Walk around to avoid prolonged standing
• In the early pregnancy there are no restrictions for travel. Regardless
of the month, if a woman plans to be in a remote area for sometime
be certain
 that she knows The nearest healthcare facility…Advise a woman who
is taking a long trip by car to plan frequent rest or stretch period. At least
2 hours, she should get out o the car and walk a short distance.. This
prevents varicosities, hemorrhoids, thrombophlebitis.. Pregnant women
can drive
Must wear seatbelts. A pad maybe placed under the shoulder harness
at the neck to avoid chafing. Purchasing a car seat would be an
Investment
because it is legally required for transporting infants.. Tracelling by
plane is not prohibited as long as its pressurized cabin.

• NUTRITION:
1. Calorie Needs – a total of 2500 caloric intake is recommended
during pregnancy to supply energy for the fetus and placenta as
well as to sustain an elevated metabolic rate.
2. Protein intake – the intake of protein increases to 60g daily.This is
best supplied by meat, poultry, fish, yogurt, eggs and milk.
3. Fat Needs - it is recommended to use vegetables oils rather than
animal oils to prevent hypercholesterolemia and coronary heart
disease.
4. Vitamin needs – vitamin intake should not be underestimate by the
women because lack of vitamins may result to pregnancy problems.
Example is Vitamin D, which is essential for calcium absorption,
when lacking can begin to diminish both fetal and maternal mineral
bone density.
5. Mineral needs
a. Calcium and phosphorus – skeleton and teeth constitute a
major portion of the fetus. Tooth formation begins as early as
8 weeks in utero. To meet the adequate supply of calcium
and phosphorus for bone formation, pregnant women need to
eat foods high in calcium and vitamin D.
b. Iodine – essential for formation of thyroxine and therefore,
proper functioning of thyroid gland.if not met, may result to
goiter of the mother or fetus that will lead to early respiratory
distress.
c. Iron – need to build a high level of hemoglobin in the fetus to
meet the necessary oxygenation during the intra-uterine life.
d. Fluoride – also aids in the formation of teeth.
e. Sodium – needs to maintain the normal fluid balance in the
body. Excess sodium is contraindicated when the mother is
hypertensive since this will result to retention of fluid thus
putting restrain on her heart as blood volume doubles.
f. Zinc – necessary for DNA and RNA synthesis
 6. Fluid Needs – needed to promote kidney function because women
must excrete waste products for two. Two glasses of fluid daily over
and above a daily quart of milk is a common recommendation.

7. Fiber Needs – for constipation.

Foods to Avoid During Pregnancy:

• Foods with caffeine

• Artificial sweeteners
• Weight loss Diets