Ch. 37 OB/GYN

Urine test

A urine sample can look for signs of health problems, such as: Urinary tract infection Diabetes Preeclampsia If your physician suspects a problem, the sample might be sent to a lab for more in-depth testing. You will collect a small sample of clean, midstream urine in a sterile plastic cup. Testing strips that look for certain substances in your urine are dipped in the sample. The sample also can be looked at under a microscope.

The American Cancer Society recommends the following guidelines for early detection of cervical cancer:

Age 21 - 29 Pap test every 3 years HPV testing should not be used for screening in this age group unless abnormal Age 30-65 Pap test combined with an HPV test every five years 65+ who have had regular screening in the previous 10 years should stop cervical cancer screening as long Women who are at high risk of cervical cancer because of a suppressed immune system - should be screened more often Women who have had a total hysterectomy should stop screening unless removal was for cancer... - who have had a hysterectomy - without removal of the cervix continue cervical cancer screening according to the guidelines above Women of any age should NOT be screened every year by any screening method. Women who have been vaccinated against HPV still get screened

Patient Education

Patients that may be at risk of their cervix opening before their baby is ready to be born may need to have a procedure performed known as a cervical cerclage. The provider will educate the patient on risks and whether the procedure might benefit them and the baby.

Subsequent Prenatal Visits

Routine prenatal visits to the physician's office usually follow the same format. It is very important to maintain continual evaluation of the mother's condition as well as that of the developing baby. Part of that responsibility belongs to the medical assistant. Each time before the patient is seen by the provider, you will:

note

The same principles apply in assisting with obstetrics patients as apply in assisting with the complete physical examination. Documentation of the prenatal history, vitals, and any past or current medical conditions of the patient must be complete and efficient. This enables the providers to give quality care to their patients. Refer to Chapter 18 for review of the anatomy and physiology of the reproductive system and information regarding pregnancy, labor, and childbirth. You need to be familiar with the terminology when discussing issues with patients.

Group B streptococcus (STREP-tuh-KOK-uhss) infection

This test is done at 36 to 37 weeks to look for bacteria that can cause pneumonia or serious infection in newborn. A swab is used to take cells from your vagina and rectum to be tested.

Nonstress test (NST)

This test is performed after 28 weeks to monitor your baby's health. It can show signs of fetal distress, such as your baby not getting enough oxygen. A belt is placed around the mother's belly to measure the baby's heart rate in response to its own movements.

Chorionic villus

What? A test done at 10 to 13 weeks to diagnose certain birth defects, including: Chromosomal disorders, including Down syndrome Genetic disorders, such as cystic fibrosis CVS may be suggested for couples at higher risk for genetic disorders. It also provides DNA for paternity testing. How is it done? A needle removes a small sample of cells from the placenta to be tested.

squamous

a type of cell that makes up the epithelium, the purpose of which is to protect underlying tissues

CIN

cervical intraepithelial neoplasia

A prenatal medical history form and a risk assessment form (Figure 37-10) are used to assess the health status of pregnant women and is generally filled out at the patient's initial visit after the pregnancy has been confirmed. The information is then scanned or entered into the electronic record. Subsequent findings during prenatal visits are recorded directly into the EHR on progress notes. Careful attention should be given to sections regarding medications, drugs, alcohol, and smoking (consumption and use); preexisting risk factors; and past menstrual and obstetrical health history.

*The effects on the fetus are well documented from certain medications, smoking, and alcohol as well as from illicit drug use. Risks are also associated with certain systemic disease conditions, sexually transmitted diseases, age, physical stature, and mental factors. Examine Figure 37-10 to identify risks of preterm births and poor pregnancy outcomes.*

A general guideline for what will occur at the initial examination is as follows:

- A complete medical history obtaining information regarding pregnancy history, past and current health, obstetric symptoms, family history, medication use, and social history - A risk assessment identifying any problems related to pregnancies and deliveries (see Figure 37-10) - A complete physical examination, includingPap smear (Procedure 37-1) - Education regarding diet, exercise, medications, and other topics preferred by the provider - Laboratory testing, which usually includes a prenatal profile to check the patient's blood type and RH factor; HIV, hepatitis, and VDRL screening; complete blood count to check the iron level and screen for infection; urinalysis and cultures to check for chlamydia and gonorrhea (refer to Unit 9 for descriptions on laboratory testing) - The patient's history of para and gravida - An estimation of the date of confinement or date of delivery - The provider's request for the patient to return in one month for the next prenatal visit

cont.

- In addition to assisting the provider, your role in prenatal evaluation and care of patients is to instill the importance of keeping regular appointments; encourage patients to eat a sensible, well-balanced diet; alert the physician of any problems or concerns; and provide patient education materials with explanations. - Naegele's rule is determined by using the first day of the last menstrual period (LMP), subtracting three months, and then adding seven days plus one year. - Your role in assessing the patient prior to her prenatal appointment can include: interviewing the patient; requesting lab and urine specimens; measuring the patient's weight and recording the findings; measuring and recording her vital signs; checking the chart to be sure all lab reports from tests ordered since the last visit are in the chart; preparing the patient if the provider will be doing an examination; and notifying the provider that the patient is ready for the examination. Pregnancy lasts about 40 weeks (starting from the first day of the patient's last normal period) and is grouped into three trimesters.

cont.

- Most providers prefer the medical assistant (or nurse) to accompany them into the exam room, not only to assist with the procedure, but also to verify their behavior in case of patient accusations. - Three main reporting categories for Pap smears are: negative for intraepithelial lesion or malignancy; epithelial cell abnormalities; and other malignant neoplasms. - To confirm pregnancy, the diagnosis is made only after the patient has been given a complete evaluation by (1) interviewing the patient and obtaining a complete prenatal health assessment and history; (2) doing a complete physical examination; (3) ordering laboratory tests, such as urinalysis and pregnancy tests, blood tests, and cultures; and (4) performing any other diagnostic test indicated by the patient's condition.

Chapter Summary

- Obstetrics focuses on pregnancy and childbirth, whereas the gynecology practice addresses diseases and disorders of the female reproductive system. - The ThinPrep Pap test technique slightly improves the detection of cancers but greatly improves the detection of precancers. This method also enables additional studies from the same sample, such as tests for the presence of HPV, chlamydia, and gonorrhea. - The ACS recommends that all women should begin cervical cancer testing (screening) at age 21. Women aged 21 to 29 should have a Pap test every three years. Beginning at age 30, the preferred way to screen is with a Pap test combined with an HPV test every five years. This is called co-testing and should continue until age 65. - Breast self-exams need to be performed by the patient monthly. Although the breast exam conducted by the provider with the annual Pap test is important, it is insufficient in detecting abnormal breast tissue between visits to the provider.

The MA´s Role is Gynecological Exams

1. Prior to bringing the patient into the examination room for the pelvic exam and Pap, the medical assistant should make the necessary preparations. As with any procedure or patient contact, wash your hands before you begin. The exam table should have a clean, protective covering. Place a gown and drape sheet on the end of the table for the patient (either cloth or disposable paper). 2. Prepare the Mayo tray with the instruments and supplies the provider will need to perform the pelvic exam and obtain the Pap test (Figure 37-2). Specula can be reusable or disposable. Place the tray in a convenient location near the end of the exam table. Cover the equipment with a towel to help allay the patient's anxiety from seeing the equipment. To aid in the inspection part of the pelvic exam, an exam lamp should also be placed within reach of the examiner's stool at the end of the table. (Most lamps are expandable and attached to the wall.)

Conducting the Examination Steps

1. The provider usually listens to the heart and lungs and does a brief general check of the patient first. Then the patient's gown is lowered to the waist while she is still sitting up for the inspection part of the breast exam and palpation for lumps and masses. When this part is completed, you will pull the table extension out to support the patient's lower legs and feet and help her lie down. This assists the provider in further palpation for any abnormalities of the breast tissue. (Often, a towel is placed over the chest to provide a sense of privacy for the patient.) Next, the provider will inspect and palpate the abdominal and pelvic areas. Remind patients to breathe slowly through the mouth to help relax abdominal muscles during the exam.

After the Examination

1. When the exam has been completed, push the stirrups and the extension of the table in and assist the patient to sit up. After lying down for the exam, the patient may feel faint or dizzy; if she attempts to stand up too quickly, she can fall. After she has let you know that she has regained her balance, help her down from the table and offer tissues to the patient to wipe away any residual lubricant. Discard the used tissues in a waste container. Ask her to get dressed and offer assistance to the patient if needed.

Next Steps: 2. The next step is for you to help the patient into the lithotomy position. Assist her in getting her feet in the stirrups, adjusting them as necessary, and place the drape sheet over her knees. Ask her to scoot down to the end of the table until the buttocks are just at the edge. Be careful in assisting patients into positions because the exam tables are usually rather narrow, and there is the possibility of a patient falling off the table. The exam lamp should be adjusted at the end of the table and the stool positioned comfortably for the provider. You will need to apply gloves as well as supply a pair for the provider to wear.

3. Adjust the lamp if necessary, to the provider's preference, so that the external perineal structures can be observed. When ready, hand the warmed speculum, handles first, to the provider. Some providers may want the speculum run under warm water to facilitate insertion and comfort for the patient. After insertion (Figure 37-5), it might be necessary to adjust the light again so that the cervix can be seen clearly within the blades of the speculum.

The MA´s Role is Gynecological Exams (2)

3. Call the patient from the reception room to prepare her for the exam. Instruct her to go to the bathroom to empty her bladder before the test. If a specimen is to be obtained, instruct her in the method of collection. A pelvic examination is uncomfortable for the patient if the bladder is full, besides making the examination difficult for the provider to perform. 4. When the patient comes back to the examination room, try to determine her level of anxiety regarding the examination. Take time to explain the procedure, letting her know what to expect, especially if it is her first time having a pelvic exam. Never assume that a patient knows about a procedure. Some patients are both afraid and embarrassed to ask questions because they believe they should already know about procedures. Try to make patients feel comfortable and at ease to help them relax for the exam.

Next Steps: 2. Remember to advise her when to expect to receive the results of the Pap test and other reports in the mail or when she should call to find out the results. Giving these instructions will decidedly reduce unnecessary phone calls to the office. If the provider requests a return appointment for the patient, politely assist her in scheduling it or direct her to the administrative area. As time permits, you may discuss patient education topics either before or after the exam as appropriate to the age and needs of the patient.

3. Return to the examination room to clean up the exam area. Wear gloves to protect yourself from disease transmission. Discard all disposables in appropriate waste containers, remove gloves, and wash hands. Restock the supplies as necessary, making the room ready for the next patient to be seen. Place the labeled specimen(s) and attached requisition form in the proper area for pickup by the lab representative.

4. Hand the endocervical broom or spatula to the provider if using the conventional method. The broom or spatula is inserted slightly into the cervical opening and twisted to obtain sample cells within and on the surface of the cervix (Figure 37-6A). The broom is withdrawn and immediately placed in the ThinPrep bottle (Figure 37-6B). It is swished 10 times through the solution, withdrawn to the top of the bottle, tapped a couple of times to knock off any remaining solution and cells, and discarded on the Mayo stand. The labeled bottle is promptly capped. The spatula is used to spread the cells on a glass slide that is then sprayed with fixative to set and placed in a protective cover.

5. The bimanual exam is performed following the collection of specimens (Pap smear and cultures) so that the lubricant will not interfere in the lab analysis. The examiner inserts two fingers (with a dime-size amount of water-soluble lubricant) into the vagina and palpates the pelvic area with the other hand (Figure 37-7). The provider then places one finger into the vagina and the other in the rectum simultaneously, checking for any abnormalities of the pelvic organs and rectum. You should hand the physician a clean glove and lubricant to prevent cross-contamination between the vaginal and rectal tissues for this exam. The provider might want to screen the patient for rectal bleeding at this time by providing a fecal sample obtained during the bimanual exam to a fecal occult test card as discussed in Chapter 35. *Alternately, instead of assisting, the medical assistant may be asked to write or scribe the findings of this examination while the provider conducts the exam. Regardless of your tasks, you can be a valuable assistant to both provider and patient.*

Next Steps: 5. After the patient is questioned and you fill in the required information on the requisition form, label the ThinPrep collection bottle and place it on the stand. Some requisition forms come with prenumbered stickers you can attach to specimens. This helps eliminate errors from mismatching requisitions to specimens. You can then instruct the patient to undress completely, tell her where to put her belongings, explain how to put on the exam gown with the opening in the front, and offer your assistance if needed. Allow the patient privacy for several minutes to change, and then knock before entering to see whether she is ready.

6. Enter the room when the patient lets you know she is ready. Pull out the footstep at the end of the exam table, and help her step up onto the exam table and sit at the end. Place the drape sheet over the top of her legs for privacy and warmth. Remember to push the footstep back in after the patient has been seated to avoid injury to you or the provider.

Next Steps: 7. Alert the provider that the patient is ready to be examined. Most providers prefer the medical assistant to accompany them into the exam room, not only to assist with the procedure, but also for legal and safety reasons as discussed in Chapter 34.

8. Because of the importance of early detection of breast cancer, providers include the breast exam during the patient's annual appointment for the Pap test and pelvic exam. Patients should be reminded to do a breast self-examination each month following their menstrual period (see the Patient Education box in Chapter 35). Giving them a pamphlet of instructions to take with them for this procedure is recommended (Figure 37-4). Explain to the patient that the exam conducted by the provider with the annual Pap test is important but insufficient in detecting abnormal breast tissue between visits to the provider. Most women discover a lump or mass in their breasts themselves and report it to the provider. This leads to early detection and treatment, which greatly increases the survival rate.

Maternal serum screen (also called quad screen, triple test, triple screen, multiple marker screen, or AFP)

A screening test done at 15 to 20 weeks to detect higher risk of: Chromosomal disorders, including Down syndrome and trisomy 18 Neural tube defects, such as spina bifida Based on test results, your physician may suggest other tests to diagnose a disorder. Blood is drawn to measure the levels of certain substances in the mother's blood.

Glucose challenge screening

A screening test done at 26 to 28 weeks to determine the mother's risk of gestational diabetes. Based on test results, your physician may suggest a glucose tolerance test. First, you consume a special sugary drink from your physician. A blood sample is taken one hour later to look for high blood sugar levels.

Initial Prenatal Visit

After the pregnancy has been confirmed by means of a urine or blood test, most providers will ask you to schedule their patient to come back in for an initial or first (OB) prenatal examination. As discussed earlier, the provider will want to confirm the laboratory tests with findings obtained from a physical examination. Schedule extra time for this appointment because a complete prenatal history will be collected. A baseline of all testing and findings is used to measure against subsequent appointments.

After the Examination

After the provider has completed the examination and talked with the patient, offer to answer any questions she might have. Encourage the patient to make her next appointment before leaving the facility. Figure 37-12 illustrates the frequency of office visits for a normal pregnancy. Persons experiencing difficulties or at high risk require more frequent evaluation. Give support and assistance by reminding her to call if she has any questions or problems.

Complete the cytology request form, whether it is electronic or a paper form (see Figure 37-3), making sure that you ask the patient all necessary questions. Many of the questions that are asked when taking a complete GYN history will be needed for the requisition form. They should include:

Age at onset of menstrual cycle Gravida (how many pregnancies the patient has had) Para (how many live births the patient has had) Abortions: How many? Were they spontaneous or elective? Date of last menstrual period (LMP) (you need to record the day it started) Regularity and duration of cycles Date of last Pap smear, result, and if any abnormal Pap smear results or biopsies in the past Contraception method used Hormone replacement therapy (HRT) if patient is taking any Date of last mammogram if had one Any GYN surgeries and dates Past and present sexual activity Any abnormal discharge or pain

Stages of Pregnancy

Although the process from fertilization through birth is discussed in detail in Chapter 18, it is important for you to understand some basics from the various stages of pregnancy and the tests and procedures that may coincide during that time. Pregnancy lasts about 40 weeks (starting from the first day of the patient's last normal period) and is grouped into three trimesters

Ultrasound exam

An ultrasound exam can be performed at any point during the pregnancy. Ultrasound exams are not routine. But it is common for women to have a standard ultrasound exam between 18 and 20 weeks to look for signs of problems with the baby and confirm the age of the fetus and proper growth. It also might be able to tell the sex of your baby. Ultrasound exam is also used as part of the first trimester screen and biophysical profile (BPP). Based on exam results, your physician may suggest other tests or other types of ultrasound to help detect a problem. Ultrasound uses sound waves to create a "picture" of your baby on a monitor. With a standard ultrasound, a gel is spread on your abdomen. A special tool is moved over your abdomen, which allows your physician and you to view the baby on a monitor.

Postpartum Visit

Approximately six weeks after giving birth, the patient will return to the clinic and see the provider for a check-up. A pelvic and breast exam will be performed as well as a physical examination of the Cesarean scar if birth was given by C-section. This essentially is the final visit with the OB provider unless other complications are occurring. As noted, a complete physical examination will be performed, and routine blood work such as a hemoglobin and a Pap smear will be obtained. Topics such as breast feeding and birth control options will take place, as well as a screening and discussion regarding mental health and a postpartum depression screening. This is a time for the patient to discuss any other concerns they may have in regard to their healing process and to seek clarification on any other issues that may have came up regarding the birthing process.

cont.

Assist the patient into supine position for the prenatal examination. Provide assistance to the provider as appropriate for the trimester (three-month period) of the patient's gestation (nine [ten lunar] months or 38 to 42 weeks). A fetoscope (special stethoscope) or a Doppler fetal pulse monitor and gel are applied to the abdomen to determine the developing fetus's heart rate. The provider may palpate the abdomen to evaluate fundic height as a means of estimating the duration of the pregnancy. If it is not as expected, it could be an indication of multiple fetuses, excess amniotic fluid, poor development of the fetus, or even fetal death. A flexible centimeter tape is used to measure the height of the fundus (top of the uterus) from the symphysis pubis to evaluate the growth of the fetus after approximately the third month. Upon completion of the examination, assist the patient to a sitting position and instruct her to dress. Record the appropriate information such as fundal height, fetal heart rate, procedures performed, and other pertinent patient or provider observations and remarks. Ultrasonography may be performed the first trimester to confirm pregnancy and later to monitor its progress (Figure 37-11). One of the most exciting times for the expectant parents is when the physician or technician locates the fetus by using ultrasound technology. The equipment is capable of displaying the image on the screen and printing out the baby's first "picture" for the proud parents to show to family and friends.

Prenatal Appointment Schedule

First and Second Trimester: Monthly or every four weeks through the 28th week Third Trimester: Every two weeks in the 30th-36th weeks. Every week in the 36+ week up to delivery. *Some patients may present to the clinic with the inquiry of their water breaking, aka ruptured membranes. In this case the provider may perform a PH test by placing a sample of vaginal fluid on a piece of litmus paper to check the acidity or alkalinity of the sample. If the sample is more alkaline than normal vaginal PH, it is likely the membranes have ruptured.*

Patient Education

Here are a few informative topics you might want to discuss with female patients who come in for gynecological exams: - Explain to patients that they should not douche routinely because it washes away natural protective vaginal secretions that aid in the resistance of possible invading microorganisms. Douching should be done only with the provider's orders. - Patients who are sexually active and not in a committed, monogamous relationship should be instructed to use condoms when engaging in sexual intercourse for protection against both sexually transmitted diseases and unwanted pregnancies. - Educate all females to perform breast self-examination at home routinely after their menstrual period. (Refer to Chapter 35.) Pamphlets for distribution can be obtained from the American Cancer Society to help patients with the procedure. - Remind all female patients over age 40 to schedule a routine mammography for early detection of breast cancer. - Explain to female patients that any of the following symptoms could mean that infection or disease is present and that they should call for an appointment: foul vaginal odor; vaginal discharge that is other than clear; unusual bleeding; vaginal itching or soreness; or any other vaginitis, pain, or discomfort. - Advise female patients to refrain from using perfumed toilet articles such as soaps or bubble baths, vaginal sprays, tampons, toilet tissue, or feminine napkins because they may be irritating to the delicate vaginal tissues. Chronic irritation can lead to infection.

More Info: Pap Test

In May 1996, after 50 years of conventional Pap testing, the U.S. Food and Drug Administration (FDA) approved a new, liquid-based method known by the brand names of ThinPrep and AutoCyte. This improved technique involves collecting the sample with a plastic endocervical "broom" and immediately placing it into a bottle of preservative solution (Figure 37-1). The broom is swished 10 times in the solution to remove the collected cells. The solution prevents the cells from drying out and significantly reduces the presence of mucus, bacteria, yeast, and pus cells on the slide prepared from the diluted cell samples in the solution. This technique slightly improves the detection of cancers but greatly improves the detection of precancers. This method also provides the ability to do additional studies from the same sample, such as tests for the presence of the human papillomavirus (HPV), trichomonas, chlamydia, and gonorrhea.

The MA´s Role is Obstetrical Exams

In addition to assisting the provider with all the examinations, your role in prenatal evaluation and care of patients is to instill the importance of keeping regular appointments; encourage patients to eat a sensible, well-balanced diet; alert the physician of any problems or concerns; and provide patient education materials with explanations. Follow your office policy regarding prenatal and childbirth classes to provide information about times and places of such programs as Lamaze classes.

Gynecological Exam

In assisting with the complete physical exam (CPE, discussed in Chapter 35), the examination of the vagina and genitalia was described as part of the total exam; however, a Pap test is not necessarily done at that time. Women may schedule appointments with their general or family practitioners for a Pap test or might prefer to see a gynecologist for this type of examination. The OB/GYN (obstetrics/gynecology) practice focuses on the female reproductive system.

Patient Education

It is very important for prenatal patients to receive regular, systematic evaluation. You must stress the importance of keeping scheduled appointments so the mother and baby can be monitored closely. The medical assistant should return to the exam room to clean up the area. Wear gloves to protect yourself from disease transmission. Discard all disposables in appropriate waste containers, remove gloves and dispose of them properly, and wash hands. Restock supplies as necessary, making the exam room ready for the next patient. Place any specimens in the area for pickup by the lab representative. To be of further assistance to both provider and patient, you might want to check all patients' charts to make sure that findings are documented in a neat and legible manner and signed by the provider. Remember, records are legal documents and may be requested at any time by insurance providers to verify the diagnosis and coding, leading to more efficient and expedient payment.

Interview the patient to determine whether any problems are being experienced, and record any remarks and symptoms. (Early treatment of problems can keep them under control and avoid later serious situations.) Request her first morning urine specimen, which she brought with her, or have her give you one now. (Some complications of pregnancy can be identified by urine tests.) Obtain a blood sample if needed: Some providers monitor the patient's iron level by checking the hemoglobin routinely. Also, maternal serum screening tests to check for chromosomal disorders, may be performed at 14-20 weeks, and the gestational diabetes test, known as a glucose tolerance test (GTT), is performed during weeks 24-28 of gestation (refer to Table 37-1).

Measure the patient's weight and record the findings. (Weight reflects the mother's nutrition and the related health of the fetus. Excess as well as insufficient weight gain is undesirable. Excess gain could indicate fluid retention.) Measure and record her vital signs. (Monitoring blood pressure is extremely important. Hypertension is indicative of complications.) Check the chart to be sure all lab reports from tests ordered since the last visit are in the chart. Also check that any other studies or referral letters are included. If the provider will be performing an examination, prepare the patient by having her remove her clothes from the waist down, unless the breasts are also to be examined, and put on a gown with the opening in the front. (Providers have different preferences for how often they will do an exam; be sure to check with your provider for specifics.) Assist the patient onto the examination table and have her sit at the end. (Provide a drape for her lap and legs if an exam is being performed.) Notify the provider that the patient is ready for the examination. After the provider reviews any returned reports and your chart notes, the patient's current general condition is discussed, and the reported problems or findings are further explored. Then it is time to proceed with the examination or additional testing if desired or needed.

Other Gynecological Procedures sims´ uterine sounds, sims´ uterine curette, randall uterine curette, and thomas-gaylor uterine punch

Other procedures can be performed to make decisions regarding the condition of the uterus and cervix. Figures 37-9A, B, C, and D show gynecological instruments used in some of these procedures. The uterine sound in Figure 37-9A is inserted into the uterus to explore the cavity and measure the depth. Note it is graduated in inches or centimeters. The curettes (Figure 37-9B and C) are used to scrape the lining of the uterus for a specimen and to remove growths or remnants of an abortion. The biopsy forceps (Figure 37-9D) permits taking a small piece of tissue for diagnostic examination. These instruments are most often used when performing surgical procedures.

Estimating the Date of Delivery

Probably the question of most interest to the expectant couple is when the baby will be born. This is known medically as the estimated day or date of delivery (EDD) or the estimated date of confinement (EDC). This can be determined, with a fair amount of accuracy, by using a formula known as Naegele's rule. The method was devised by Franz Naegele, a German obstetrician, in the early nineteenth century. The period of gestation (conception to birth) is determined by using the first day of the last menstrual period (LMP), subtracting three months, and then adding seven days plus one year.

First Trimester (weeks 1-12): Body changes and hormonal changes occur, and many even detect symptoms during the first few weeks. - Extreme tiredness - Tender swollen breasts, protruding nipples - Upset stomach; heartburn; vomiting - Cravings or noncravings for certain foods; weight gain or loss - Mood swings - Constipation and frequent urination - Headache

Second Trimester (weeks 13-28): Most claim easier than the first trimester, nausea and fatigue resolve, and new body changes occur. - Body aches - Stretch marks - Skin darkening around the nipples - Line on skin from belly button to pubic area - Swelling of ankles, fingers, and face Third Trimester (weeks 29-40): Many of the same symptoms occurring during the second trimester continue, and some have increased frequency of urination and difficulty breathing due to the baby getting bigger and putting pressure on their organs. - Heartburn - Hemorrhoids - Breasts may leak a pre-milk substance known as colostrum - Trouble sleeping - Contractions (real or fake)

The Pap Test

The Papanicolaou (Pap) technique is a cytological screening test to detect cancer of the cervix. This method of detection was developed by an American physician, George N. Papanicolaou, in 1883. This simple smear technique used samples taken from the vagina, the cervix, and the endocervix to look for atypical cytology. The samples were smeared onto slides and then sprayed with a fixative or placed in an alcohol solution and sent to a lab. Studies have shown that the technique produced many inadequate specimens, sometimes requiring repeating the procedure. Up to two-thirds of the false negative reports were caused by the limitations of the sampling technique and the slide preparation. Often, cells on the slide were piled up so those underneath could not be seen. Additionally, cervical cells were hidden by pus cells from infection, yeast cells, bacteria, and increased mucus. Therefore, precancerous cells were not visible, and the results were incorrectly reported negative. Furthermore, if the slide was not treated immediately after the smear was done, the cells dried out and became distorted, leading to possible reading errors.

Reporting Pap Results

The system most widely used to describe Pap test findings is the Bethesda system. It was developed in 1988 and revised in 1991 and 2001. There are three general categories: Negative for intraepithelial lesion or malignancy (Means there are no signs of cancer or precancerous changes. Other findings may be reported, such as yeast, herpes, Trichomonas, or cellular changes caused by irritation or infection.) Epithelial cell abnormalities (Means the cells of the lining layer of the cervix show changes that might be cancer or a precancerous condition. The cells are divided into atypical squamous cells, low-grade squamous intraepithelial lesions (SILs), (c) high-grade SILs, and (4) squamous cell carcinoma. These findings require repeat Pap tests and other interventions such as colposcopy (examining the cervix with a magnifying lens instrument and biopsy.) Other malignant neoplasms (Means there is likely an invasive squamous cell cancer. Additional diagnostic tests will be performed, followed by radiation, chemotherapy, or radical surgery.)

Glucose tolerance test

This test is done at 24 to 28 weeks to diagnose gestational diabetes. Your physician will tell you what to eat a few days before the test. Then you cannot eat or drink anything but sips of water for 14 hours before the test. Your blood is drawn to test your "fasting blood glucose level." Then you will consume a sugary drink. Your blood will be tested every hour for three hours to see how well your body processes sugar.

First trimester screen

What is it? A screening test done at 11 to 14 weeks to detect higher risk of: Chromosomal disorders, including Down syndrome and trisomy 18 Other problems, such as heart defects It also can reveal multiple births. Based on test results, your physician may suggest other tests to diagnose a disorder. This test involves both a blood test and an ultrasound exam called nuchal translucency (NOO-kuhl trans-LOO-sent-see) screening. The blood test measures the levels of certain substances in the mother's blood. The ultrasound exam measures the thickness at the back of the baby's neck. This information, combined with the mother's age, help physician determine risk to the fetus.

Biophysical profile (BPP)

What is it? This test is used in the third trimester to monitor the overall health of the baby and to help decide if the baby should be delivered early. How is it done? BPP involves an ultrasound exam along with a nonstress test. The BPP looks at the baby's breathing, movement, muscle tone, heart rate, and the amount of amniotic fluid.

Amniocentesis

What? This test can diagnosis certain birth defects, including: - Down syndrome - Cystic fibrosis - Spina bifida It is performed at 14 to 20 weeks. It may be suggested for couples at higher risk for genetic disorders. It also provides DNA for paternity testing. How is it done? A thin needle is used to draw out a small amount of amniotic fluid and cells from the sac surrounding the fetus. The sample is sent to a lab for testing.

Obstetrics focuses on pregnancy and childbirth, whereas the gynecology practice addresses diseases and disorders of the female reproductive system

When a patient calls a general or family practice for an appointment, be sure to make a distinction between a physical exam and a gynecological exam with a Pap test so that the appropriate amount of time is allotted, and proper instructions are given. Remember that the CPE is a review of systems (ROS) of the total body, and the gynecologic exam is of the female reproductive organs only.

Obstetrical Exams

When patients suspect that they are pregnant, their visit to the physician is to confirm pregnancy. Usually, the patient has missed one or two menstrual periods. Because home pregnancy tests are convenient and accessible, many women have already tested their urine at home prior to coming into the office. However, even after having performed the home test, they still may not be certain of the results. The diagnosis is made by the provider only after the patient has been given a complete evaluation. This is generally done by (a) interviewing the patient and obtaining a complete prenatal health assessment and history (b) doing a complete physical examination (c) ordering laboratory tests such as urinalysis and pregnancy tests, blood tests, and cultures (d) and performing any other diagnostic test indicated by the patient's condition.

Pap Patient Education

When the patient is scheduled for a Pap test, she must be given clear instructions to follow in preparation for the test. The following are recommended by the American Cancer Society for accurate results: - Do not use tampons, birth control foams, jellies, or other vaginal creams for 48 hours before the test. (They alter the cervical and vaginal environment.) - Do not douche for 48 hours prior to the test. (Douching could wash away exfoliated cancer cells and cause the test to be falsely reported as negative.) - Do not have sexual intercourse for 48 hours before the test. (This adds extra cells and fluid to the environment, making reading more difficult.) - Try to schedule the Pap test at least five days after the menstrual period. Avoid scheduling during the period. (Red blood cells make the test more difficult to read.)

lesion

a change in the tissue cells or a wound

condyloma

a lesion caused by human papillomavirus

malignant

a lesion that spreads out of the epithelium into underlying tissues

CIS

carcinoma in situ

epithelium

cellular tissue that covers the surface of a body or that lines the body cavity

reparatives changes

changes in cells as they divide rapidly in an attempt to repair damanged tissues

reactive changes

changes in cells caused by their reaction to infectious agents or a foreign body

HPV

human papillomavirus

Figure 37-8 lists and defines some terms used in the cytology reports of Pap tests.

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atypical

not typical

A normal pregnancy can range from 37 to 41 weeks, so exact dates are not possible. An infant born before the 37th week is called premature, is considerably underweight, and presents challenges due to lack of development.

note

Table 37-1 describes some of the common tests and procedures that may be administered during the course of the pregnancy. Each pregnancy is unique, and whether or not a procedure or test is performed will be at the discretion of the provider and patient based on need.

note

epithelial

pertaining to epithelium

dysplasia

precancerous lesion

SIL

squamous intraepithelial lesion

glandular

the cell making up the epithelium of a body cavity