Editing Maternal and Newborn Nursing (section)

== Antepartum Care ==

=== Visit schedule and routine screening ===

A common schedule for an uncomplicated pregnancy is every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, then weekly until birth. Each visit includes weight, blood pressure, urine dipstick for protein and glucose, fundal height, fetal heart rate, fetal movement, and a review of danger signs.

Initial labs typically include blood type and Rh with antibody screen, CBC, rubella and varicella immunity, hepatitis B surface antigen, HIV, syphilis screening, gonorrhea and chlamydia testing, urine culture, and cervical cancer screening as indicated.

* '''Gestational diabetes screening at 24 to 28 weeks''', usually a 50 g 1-hour glucose challenge followed by a 100 g 3-hour oral glucose tolerance test if the screen is elevated.
* '''Group B ''Streptococcus'' (GBS) rectovaginal culture at 36 0/7 to 37 6/7 weeks.''' A positive culture, GBS bacteriuria in this pregnancy, or a previous infant with GBS disease means '''intrapartum''' IV antibiotic prophylaxis, typically penicillin G, ideally at least 4 hours before birth. Treating GBS antepartum does not prevent neonatal disease; the antibiotic must be given in labor.
* '''Rh-negative patients''' receive '''Rho(D) immune globulin at about 28 weeks''' and again '''within 72 hours after birth if the newborn is Rh positive'''. It is also indicated after miscarriage, ectopic pregnancy, elective termination, amniocentesis, chorionic villus sampling, external cephalic version, and abdominal trauma. Rho(D) immune globulin prevents maternal ''sensitization''; it does nothing once antibodies already exist, which is why the antibody screen matters.

=== Fetal assessment ===

* '''Fundal height''': the uterus is at the symphysis pubis around 12 weeks and at the umbilicus around 20 weeks. From roughly 18 to 32 weeks, fundal height in centimeters approximates gestational age in weeks within about 2 cm. A height more than about 2 cm larger than dates suggests multiple gestation, polyhydramnios, macrosomia, or wrong dates; smaller suggests fetal growth restriction, oligohydramnios, or wrong dates.
* '''Fetal heart tones''': audible by Doppler around 10 to 12 weeks, by fetoscope around 18 to 20 weeks. Normal baseline is '''110 to 160 beats per minute'''.
* '''Quickening''': first maternal perception of movement, about 18 to 20 weeks in a first pregnancy and 14 to 16 weeks in later pregnancies.
* '''Fetal movement (kick) counts''': a widely taught method is to have the patient rest on her side after a meal and count movements; fewer than 10 distinct movements in 2 hours warrants calling the provider. Teach that a ''decrease'' in the baby's usual pattern is always reported, never watched at home.
* '''Nonstress test (NST)''': '''reactive''' is reassuring and means at least 2 accelerations in 20 minutes, each 15 beats above baseline lasting 15 seconds, in a fetus 32 weeks or more (10 beats for 10 seconds before 32 weeks). '''Nonreactive''' requires further testing, not immediate delivery.
* '''Biophysical profile (BPP)''': 2 points each for NST, fetal breathing, gross body movement, tone, and amniotic fluid volume. 8 to 10 is reassuring, 6 is equivocal, 4 or less is concerning.
* '''Contraction stress test''': '''negative''' (no late decelerations with contractions) is the ''good'' result. In this one test the confusing convention is that negative equals normal.
* '''Amniocentesis''' after about 15 weeks assesses genetic status and, less often now, fetal lung maturity (lecithin to sphingomyelin ratio of 2:1 or greater, presence of phosphatidylglycerol). Have the patient empty her bladder before a second- or third-trimester procedure, monitor the fetal heart rate afterward, and give Rho(D) immune globulin if the patient is Rh negative.

=== Nutrition and teaching ===

* Weight gain guidance by prepregnancy BMI: underweight 28 to 40 lb, normal weight 25 to 35 lb, overweight 15 to 25 lb, obese 11 to 20 lb.
* '''Folic acid 400 to 800 mcg daily''' before conception and in early pregnancy prevents neural tube defects; 4 mg daily is recommended with a prior affected pregnancy. Iron requirement is about 27 mg daily. Calcium about 1,000 mg daily.
* Avoid alcohol entirely (no known safe amount; fetal alcohol spectrum disorders), avoid tobacco and cannabis, limit caffeine, avoid high-mercury fish (shark, swordfish, king mackerel, tilefish), avoid unpasteurized dairy, deli meats unless steaming hot, and raw or undercooked meat, fish, and eggs (''Listeria'', ''Toxoplasma'', ''Salmonella''). Avoid changing cat litter and wear gloves when gardening (toxoplasmosis).
* Avoid live vaccines in pregnancy (MMR, varicella). Inactivated influenza vaccine and Tdap (given at 27 to 36 weeks for infant pertussis protection) are recommended ''during'' pregnancy.
* Common discomforts and nursing responses: nausea (small dry carbohydrate before rising, small frequent meals), heartburn (small meals, upright after eating, avoid lying flat), constipation (fiber, fluids, activity; docusate rather than stimulant laxatives), varicosities and edema (elevate legs, avoid crossing legs, support hose), and back pain (pelvic tilt, good body mechanics, low-heeled shoes).

=== Danger signs the patient must report immediately ===

Vaginal bleeding; leaking of fluid; severe or persistent headache; visual changes such as blurring, spots, or photophobia; right upper quadrant or epigastric pain; sudden swelling of the face and hands; persistent vomiting; fever; painful urination; decreased fetal movement; regular contractions before 37 weeks.