ANTEPARTAL CARE
LEARNING ACTIVITY MODULE
SOUTHEASTERN LOUISIANA UNIVERSITY
SCHOOL OF NURSING
N 403
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LEARNING ACTIVITY MODULE
ANTEPARTAL CARE
N403
PURPOSE:
To provide the student the opportunity to review and practice routine skills necessary for safe
and competent care of the pregnant woman during the antepartal period.
OBJECTIVES:
By the end of the antepartal care skills lab/module, the student will be able to:
1.
Discuss the purpose, procedure, and interpretation of non stress test and contraction stress
tests.
2.
Identify the purpose and procedure of amniocentesis.
3.
Demonstrate the performance of Leopold's maneuvers.
4.
Demonstrate proper placement of ultrasound device (doppler) or fetoscope for listening
to fetal heart sounds/rate and thereby performing intermittent auscultation.
5.
Demonstrate how to measure fundal height.
6.
Demonstrate how to properly position and drape a prenatal woman for a pelvic exam.
7.
Demonstrate how to perform pelvic exam and collection of cervical or urethral
specimens.
REQUIRED RESOURCES
Videos:
Physical Assessment: Examination of the Pregnant Woman (skills lab)
Performing Internal Vaginal Exam and Obtaining Pap Smear and GC and Chlamydia Cultures
(skills lab)
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REQUIRED READINGS:
Lowdermilk, D., & Perry, S. (2012). Maternity & women’s health care (10th ed.). St. Louis,
MO: Mosby Elsevier.
1. Fetal Assessment and stress tests (pp. 640-653)
Amniocentesis (pp. 645-646)
Doppler (p. 341)
2. Leopold's Maneuvers (p. 443)
3. Measurement of fundal height (pp. 341-342)
4. Performing a Vaginal exam and collection of PAP smear and cultures. (pp. 85-87)
5. Positioning and draping for pelvic exam (pp.84-85)
STUDENT ACTIVITIES:
-Read the information in the module.
-Before skills lab, read the assigned readings.
-View the videos and CD-ROMs.
-Inspect the module box for necessary items/gather other materials.
Practice the following procedures:
1. Role play with a student volunteer or on a model the procedure of Leopold's maneuver.
2. Practice on a student volunteer or a model the listening for fetal heart sounds/rate
(intermittent auscultation) with a fetoscope/doppler. Practice listening in all four quadrants.
3. Practice on a student volunteer or a model the measuring of fundal height.
4. Practice with a student volunteer (fully clothed!) or a model the proper way to position and
drape a woman for a pelvic exam.
5. Discuss the purposes and procedures for stress test, contraction test and amniocentesis.
-Please straighten the area before leaving (make beds, return models to green cabinets
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MATERIALS AND SUPPLIES:
-fetoscope or ultrasound stethoscope (if these are not available then use own stethoscope)
-measuring tape
-small rolled towel
-vaginal speculums
-gloves
-PPE
-lamp
-pap smear/culture kits
Practice lab area:
-laptop and projector
-TV/VCR
-CD-ROMs
-female pelvic model
-abdominal model
-sheets for draping
-table
-pillow
Bring own stethoscope and Lowdermilk textbook to lab.
LEOPOLD's MANEUVERS:
RATIONALE:
Leopold's Maneuvers are performed to identify the number of fetuses; identify the presenting
part, the fetal lie, and the fetal attitude; determine the degree of the presenting part's descent into
the pelvis of the woman; and identify the probable best location to hear the fetal heart tones on
the woman's abdomen.
PROCEDURE:
1. Wash hands
2. Ask the woman to empty bladder
3. Have woman supine with a pillow under head and knees slightly flexed
4. Place small rolled towel under woman's right hip
5. Feel for the fetal part that lies at the fundal area. Head will be round, firm, and move freely.
(This phase will determine fetal lie and presentation.)
6. Feel with palm and palpate the contour of the fetal back
and then the irregular parts (hands, feet). (This helps to determine fetal presentation.)
With the hand go further down and determine which part is presenting into the pelvis (If
the head is not engaged then determine the attitude of the head.)
7. Turn toward the woman's feet and with two hands outline the fetal head. (When the
presenting part has descended then only a small portion may be outlined.)
8. Documentation would include fetal presentation, position and lie and whether the
presenting part is flexed or extended, engaged or free floating.
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DETECTING FETAL HEART TONES:
RATIONALE:
Detecting fetal heart sounds by listening and counting fetal heart rate takes practice. The PMI
(point of maximum intensity of the fetal heart rate is the location on the abdomen where the FHR
is expected to be heard the loudest.) The best place is usually over the fetal back. Leopold's
Maneuvers can determine fetal presentation and position which will aid in determining the best
place to hear fetal heart tones.
PROCEDURE:
1. Wash hands
2. After performing Leopold’s' Maneuver, determine the expected location of the loudest
heart sounds
3. Find all sites on the model or student volunteer
(RSA,ROP,RMA,ROA,LSA,LOP,LMA,LOA)
4. Practice listening with fetoscope or ultrasound stethoscope (if these are not available then
practice with stethoscope)
5. Practice counting fetal heart rate
6. What is the "normal" range for FHT's?
MEASURING FUNDAL HEIGHT:
RATIONALE:
During the second trimester the uterus enters the abdominal area and can be palpated. There is a
normal progression of the rise (height) of the uterus above the symphysis pubis. This is an
indicator of fetal growth and can be used to identify possible fetal problems (for example, too
low for gestation may mean growth problem or too high for gestation may mean presence of
hydramnios). Most accurate between 18 and 30 weeks gestation.
PROCEDURE:
1. Due to problems with inaccurate measurements it is best for the same person to measure
the fundal heights during each prenatal visit. Also, it is best for the bladder to be empty.
2. Wash hands
3. Have the model or volunteer lie on back on table (measurements can differ based on
whether head is flexed on a pillow and whether leg(s) are flexed)
4. Using tape measure, measure from the upper border of the symphysis pubis to run the full
length of the uterus with the tape measure remaining in contact with the skin. The upper
curve of the fundus is not included. The top is measured at the top of the fundus with the
hand. Record the measurements in centimeters
5. What is the "normal" height in centimeters for a 30 week gestation?
NON STRESS TEST (Fetal Activity Determination):
RATIONALE:
NST are done to determine fetal well-being. In a normal fetus with an intact CNS, 90% of gross
fetal body movements are associated with accelerations of FHR. Performed easily in outpatient
setting, is inexpensive, and has no known contraindications.
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PROCEDURE:
1. Place client in a reclining chair (or in a semi-Fowler’s position) to avoid supine
hypotension).
2. Apply doppler transducer to detect FHR and a tocotransducer to detect uterine
contractions or fetal movements.
3. The strip chart is monitored for signs of fetal activity and a concurrent acceleration of
FHR, and the client’s blood pressure is monitored. Note: If evidence of fetal movement
is not apparent on the strip, the woman may be asked to depress a button on a hand-held
event marker connected to the monitor when she feels movement. The movement is then
recorded on the strip.
4. The test is considered reactive when:
a. Two or more accelerations of 15 beats/min lasting 15 seconds over a 20-minute
period.
b. Normal baseline rate
c. Long-term variability amplitude of 10 or more beats/minute.
5. If the test does not meet the criteria after 40 minutes, it is considered nonreactive, in
which case further assessments are needed with a Contraction Stress test or Biophysical
Profile.
CONTRACTION STRESS TEST:
RATIONALE: Devised as a graded stress test. Its purpose was to identify the jeopardized fetus
that was stable at rest but showed evidence of compromise after stress. Uterine contractions
decrease uterine blood flow and placental perfusion. If this decrease is sufficient to produce
hypoxia in the fetus, a deceleration of FHR will result beginning at the peak of the contraction
and persisting after its conclusion (late deceleration). In a healthy fetoplacental unit, uterine
contractions usually do not produce late decelerations, whereas if there is underlying
uteroplacental insufficiency, contractions will produce late decelerations.
PROCEDURE:
1. Client is placed in Semi-fowler’s position or sits in a reclining chair.
2. Doppler transducer is used to monitor FHR for 10 minutes for baseline rate, long-term
variability. A tocotransducer is used to monitor for the possible occurrence of
spontaneous contractions.
3. For Nipple-Stimulated Contraction Test:
a. Warm moist washcloths are applied to both breasts for several minutes.
b. The client is asked to massage one nipple for 10 minutes (massaging the nipples
causes a release of oxytocin from the posterior pituitary).
c. An alternative approach is to massage the nipple for 2 minutes, rest for 2 minutes,
and continue for four cycles of massage and rest. When adequate contractions or
hyperstimulation occurs, stimulation should be stopped.
4. For Oxytocin-Stimulated Contraction Test: Used when Nipple stimulation test is
unsuccessful. An IV infusion of oxytocin is infused beginning at 0.5 mU/min and
increased by 0.5 mU/min at 15 to 30 minute intervals until three uterine contractions of
good quality are observed within a 10-minute period. After interpretation of FHR
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pattern, the oxytocin infusion is halted and the maintenance IV solution infused until
uterine activity has returned to prestimulation level.
5. Interpretation: If no late decelerations are observed with contractions, the findings are
considered negative. Repetitive late decelerations, occurring with most contractions,
render the test positive.
AMNIOCENTESIS:
RATIONALE: Performed to obtain amniotic fluid, which contains fetal cells. Indications
include prenatal diagnosis of genetic disorders or congenital anomalies (neural tube defects in
particular), assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease.
PROCEDURE: Under direct ultrasonographic visualization, a needle is inserted
transabdominally into the uterus, amniotic fluid is withdrawn into a syringe, and the various
assessments are performed.
Nursing Interventions
1. Assess maternal vital signs every hour.
2. Assess for fetal heart tones and for uterine contractions via external electronic fetal
monitoring every hour.
POSITIONING AND DRAPING FOR EXAM:
RATIONALE: Pelvic exams are done during the prenatal period at various intervals to help
determine the maternal and fetal well being. It is used later during the prenatal period to also
detect dilation and effacement.
PROCEDURE:
1. Wash hands
2. Place model or volunteer (fully clothed!) in the lithotomy position on a table (no foot
holders are available so pretend the position) In reality the woman will not be clothed
from the waist down.
3. Place a pillow under head
a. Drape sheet over abdomen and legs leaving genital area exposed.
Question?? What do you do if a woman can not tolerate the lithotomy position but needs a pelvic
exam?
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OBTAINING PAP SMEAR AND GC AND CHLAMYDIA CULTURES:
INTERNAL VAGINAL EXAM
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Explain purpose and procedure of exam
Request client to remove all clothing from the waist down and sit on end of exam table
Gather equipment
Wash hands
Open equipment and place so it is easily reached
Place waste can so is easily accessible
Position goose neck lamp for best lighting
Position client in lithotomy position and drape appropriately
Have client position buttocks at edge of exam table and feet in stirrups – adjust stirrups
for length of client’s legs
Don clean gloves
Assist client to relax -- talk to her; have her take slow, deep breaths and concentrate on
rhythm of breathing
Explain to client what you are doing as you move through the procedure
Tell client that the examiner is going to touch her leg
Open introitus by inserting middle and index finger of non-dominant hand
Insert vaginal speculum in oblique fashion with dominant hand
Turn speculum to horizontal position and remove fingers of non-dominant hand
Open speculum and visualize the cervix
Inspect cervix for inflammation, lesions, discharge. Note any foul odor and
character of lesions and discharge
Obtain specimens, as needed
Remove speculum by first closing blades of vaginal speculum and then removing from
vaginal canal. Hold rear handle of speculum and do not turn speculum.
OBTAINING PAP SMEAR:
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Explain procedure and purpose to client. Also explain what sensations client will feel as
the specimen is obtained (i.e. pressure but not pain)
Verify that client has not douched, used vaginal medications or had sexual intercourse for
24 hours prior to procedure. These will interfere with results of the test. The test should
likewise be rescheduled if cervix is inflamed and bleeding or if client is menstruating.
After inserting speculum, place S-shaped end of the cervical spatula just within the
cervical canal at the external os. Rotate the spatula 360 degrees so that the surface at
squamocolumnar junction is firmly scraped.
May repeat procedure with cytology brush (see agency protocol)
Mucous containing endocervical cells is spread on slide, then lightly sprayed with
fixative and allowed to dry
Send to lab in appropriate container
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COLLECTION OF CULTURES FOR GC AND CHLAMYDIA
FEMALE:
1. Explain procedure and purpose to client. Also explain what sensations client will feel as
the specimen is obtained (i.e. pressure but not pain)
2. Have all equipment opened and readily accessible
3. Have garbage can accessible
4. After inserting speculum, insert first Q-tip into cervical os. Turn Q-tip 360 degrees and
then remove and discard. (This removes excessive mucous/discharge)
5. Insert second Q-tip into cervical os. Turn Q-tip 360 degrees and then remove.
Place Q-tip in appropriate container which has been labeled and then send to lab.
MALE:
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5.
Explain procedure and purpose to client.
Explain that client may experience a burning sensation when culture is obtained
Inspect external genitalia—being especially watchful for lesions or rash
Have client hold penis.
Insert Q-tip into urinary meatus. (Insert ¾ of Q-tip bottom into urinary meatus and turn
360 degrees.
6. Remove Q-tip and place in appropriate container
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