Chapter 13 Antepartum nursing assessment

signs of psychologic problems during prenatal

- • Increasing anxiety • Depression or feelings of sadness • Inability to establish communication • Inappropriate responses or actions • Denial of pregnancy • Inability to cope with stress • Intense preoccupation with the sex of the baby • Failure to acknowledge quickening • Failure to plan and prepare for the baby (for example, living arrangements, clothing, feeding methods) • Indications of substance abuse

Nagele's Rule

-A method of determining the estimated date of birth (EDB): after obtaining the first day of the last menstrual period, subtract 3 months and add 7 days. -accurate determiner of EDB if a woman has a history of menses every 28 days, has an accurate LMP, and was not utilizing hormonal contraception prior to conception. -unsure LMP, irregular menstrual cycles, breastfeeding women, amenorrhea, or hormonal contraception use, an ultrasound is done to visualize the gestational sac and obtain measurements of the embryo/fetus to determine EDB.

testing for fetal trisomy and neural tube defects

-All pregnant women, regardless of age, should be offered screening for fetal chromosome anomolies (aneuploidy) including Down syndrome, trisomy 18, trisomy 13, and Turner syndrome. -First trimester screening is available at many centers using ultrasound assessment of the thickness of the fetal nuchal fold (called nuchal translucency [NT]) combined with serum screening for free β-hCG and for pregnancy-associated plasma protein A (PAPP-A). - Increased NT, elevated free β-hCG, and reduced PAPP-A suggest aneuploidy. Women with these findings are offered genetic counseling and chorion villus sampling or second trimester amniocentesis for diagnosis. -The quadruple screen (quad screen) is a safe, useful screening test performed on the mother's serum between weeks 15 and 20 of pregnancy; used to detect levels of specific serum markers—alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol (UE), and inhibin-A (a placental hormone). -Noninvasive prenatal testing for fetal aneulopoidy (trisomy), specifically trisomy 13, trisomy 18, and trisomy 21, is also available using cell-free fetal DNA from the blood of pregnant women.

Fetal development - quickening

-Fetal movements felt by the mother or perception of life—quickening—may give some indications that the fetus is nearing 20 weeks' gestation.

current pregnancy assessment

-First day of last normal menstrual period (LMP). Is this a sure date or uncertain? Within days? Does she know the last month of menses? Do her cycles normally occur every 28 days, or do her cycles tend to be longer or shorter? Does she have monthly menses? Was the LMP normal in duration and bleeding? Was she using any form of contraception? • Presence of cramping, bleeding, or spotting since LMP. • Woman's opinion about time when conception occurred and when infant is due? Was she charting her cycles? • Woman's attitude toward pregnancy. (Is pregnancy planned or unplanned? Wanted?) • Date of positive pregnancy test; date of negative pregnancy test. • Any pregnancy discomforts since LMP, such as nausea, vomiting, urinary frequency, fatigue, breast tenderness, constipation, fever, headaches.

Screening tests

-Tests completed at the initial visit include a Pap smear, complete blood count, HIV screening, rubella titer, ABO and Rh typing, urine culture, and hepatitis B screen, sexually transmitted infections such as syphilis, HIV, chlamydia, and gonorrhea. -Hemoglobin electrophoresis should be performed in women of African, Southeast Asian, and Mediterranean decent to evaluate for sickle cell disease and thallasemias. -prenatal screening for cystic fibrosis -A tuberculin test (either PPD or QuantiFERON®-TB Gold) should also be completed on women who are considered to be high risk. - not born in the U.S, known exposure to tuberculosis, and healthcare workers who care for patients with tuberculosis. -Women who have not received varicella immunization or report a negative disease history should also be evaluated for varicella immunity. - Screening for gestational diabetes mellitus (GDM) is completed between 24 and 28 weeks' gestation; done using a 50-g 1-hour glucose screen; women at average risk should be screened at 24 to 28 weeks' gestation using a 75-g 2-hour oral glucose tolerance test (OGTT) -rectal and vaginal swabs of the mother are taken at 35 to 37 weeks' gestation to screen for group b strept

TPAL

-term: number of term births the woman has experienced (number of infants born at the 37 0/7 weeks' gestation or beyond) -preterm: number of preterm births (births after 20 weeks' but before 37 0/7 weeks' gestation, whether living or stillborn) -abortion: number of pregnancies ending in either spontaneous or therapeutic abortion (before 20 weeks' gestation) -living: number of currently living children to whom the woman has given birth

Assessment of Pelvic Adequacy

-the examiner assesses the pelvis vaginally to determine whether the size and shape are adequate for a vaginal birth - clinical pelvimetry, performed by physicians and advanced nurses -should not be used to determine if a patient is appropriate to attempt a vaginal birth.

fetal development - ultrasound

-transabdominal ultrasound can detect a gestational sac as early as 4 to 5 weeks after the LMP, fetal heart activity by 6 to 7 weeks, and fetal breathing movements by 10 to 11 weeks of pregnancy. - Crown-to-rump measurements can be made to assess fetal age from 4 days until about 12 weeks

Subsequent patient history

- The nurse should give the woman sufficient time to ask questions and to voice concerns. -The nurse should be sensitive to religious, spiritual, cultural, and socioeconomic factors that may influence a family's response to pregnancy & woman's expectations of the healthcare system; nurse can avoid stereotyping by asking each woman about her expectations for the antepartum period. -During the prenatal period, it is essential that the nurse begin assessing the developing readiness of the woman and her partner to take on the responsibilities of parenthood successfully - Depression during and after pregnancy is a common problem; Infants of depressed women are at increased risk for their social emotional development, cognitive development, behavioral development, and physical health to be negatively impacted - should be evaluated and monitored closely

assessment of pelvic adequacy - pelvic outlet

- The transverse diameter of the outlet is measured by placing the fist between the ischial tuberosities. -The mobility of the coccyx is determined by pressing down on it with the forefinger and middle finger during the initial vaginal examination -The subpubic angle is estimated by palpating the bony structure externally with two fingers placed side by side at the border of the symphysis; should be 85-90 degrees -pubic ramus is expected to be short and concave inward, as opposed to straight and long. -The height and inclination of the symphysis pubis are measured, and the contour of the pubic arch is estimated; Height can be determined by placing the index finger of the gloved hand up to the superior border of the symphysis; Inclination can be determined by externally placing one finger on the top of the symphysis while the internal finger palpates the internal margin - The examiner uses two fingers to determine the contour of the pubic arch. This provides information on the width of the angle at which these bones come together -if pubic arch is narrow, the infant's head may be pushed backward toward the coccyx

fetal development - fetal heartbeat

- The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. -It may detect fetal heartbeat at about 10 to 12 weeks' gestation. -FHT range: 110-160 -ultrasound completed if the nurse is unable to auscultate between 10 and 12 weeks, because there may be a discrepancy of EDB, twins, or a missed abortion.

Uterine assessment - fundal height

-used as an indicator of uterine size, although this method is less accurate late in pregnancy. - measure the distance in centimeters from the top of the symphysis pubis over the curve of the abdomen to the top of the uterine fundus - fundal height should be measured by the same examiner each time. Maternal position (trunk elevation, knee flexion) may influence fundal height measurement. If the woman is very tall or very short, fundal height may also differ. - In the third trimester, variations in fetal weight decrease the accuracy of fundal height measurements. -A lag in the progression of fundal height from month to month may indicate intrauterine growth restriction (IUGR), or oligohydraminos, and a sudden increase in height may indicate the presence of twins, hydramnios, or a large for gestational age (LGA) fetus; abnormal, verify w/ ultrasound

Postterm

42 0/7 weeks and beyond

gravida

Any pregnancy, regardless of duration, including present pregnancy.

primipara

a woman who has borne one viable child

nullipara

a woman who has never borne a viable child

primigravida

a woman who is pregnant for the first time

initial patient history

course of a pregnancy depends on a number of factors, including the past pregnancy history (if this is not a first pregnancy), prepregnancy health of the woman, presence of disease/illness states, family history, emotional status, and past health care.

Uterine assessment - physical

done at the patient's first prenatal visit to evaluate for potential health concerns but also to evaluate uterine size to assist with dating the pregnancy.

other ways EDB can be estimated

fundal height, uterine size, auscultation of fetal heart tones, and timing of quickening.

Danger signs of pregnancy

gush of fluid or bleeding from vagina - regular uterine contractions -seizures or convulsions -absence or decreased fetal movement -dysuria -severe headache - visual disturbances - abdominal pain -persistent vomiting, fever, chills - swelling face and fingers

multigravida

woman who has been pregnant more than once

multipara

woman who has given birth to two or more children

cell free fetal dna testing risk factors

• Advanced maternal age (women 35 or older at the time of childbirth) • Ultrasound findings indicating an increased risk of trisomy • History of previous pregnancy with a fetus with aneulopoidy • Positive test for aneulopoidy, whether from first trimester testing or a quad screen

para

Birth after 20 weeks' gestation, regardless of whether the infant is born alive or dead.

abortion

Birth that occurs before 20 weeks' gestation or the birth of a fetus-newborn who weighs less than 500 g; occur spontaneously or it may be induced by medical or surgical means.

nulligrava

Condition of never having been pregnant

early term

Extending from 37 0/7 weeks through 38 6/7 weeks' gestation

full term

Extending from 39 0/7 weeks through 40 6/7 weeks' gestation

Late term

Extending from 41 0/7 weeks through 41 6/7 weeks' gestation

preterm or premature labor

Labor that occurs after 20 weeks but before the completion of 37 weeks of gestation

postterm labor

Labor that occurs after 42 weeks of gestation.

stillbirth

Loss of fetus after 20 weeks of pregnancy

current medical history

-Weight (prepregnancy and current), height, body mass index (BMI) (determine recommended weight gain). • Blood type and Rh factor. • General health, including nutrition (dietary practices or problems such as vegetarianism, lactose intolerance, food allergies), regular exercise program (type, frequency, duration), monthly breast exams; eye exam; date of last dental exam. • Any medication use (nonprescription, homeopathic, or herbal medications); medications taken since LMP? • Previous or present use of alcohol, tobacco, or caffeine (if yes, ask about amounts consumed each day); planning cessation? • Illicit drug use or abuse (specific drugs such as cocaine, crack, marijuana, methamphetamines); planning cessation? • Drug allergies, latex allergy or sensitivities: what type of reaction? • Potential teratogenic insults to this pregnancy, such as viral infections, medications, X-ray examinations, surgery, or cats in the home (source of toxoplasmosis). • Presence of chronic disease conditions, such as diabetes, hypertension, asthma, cardiovascular disease, renal problems, or thyroid disorders. • Infections or illnesses since LMP (flu, measles). • Record of immunizations (especially rubella); up to date? • Presence of any abnormal signs/symptoms.

subsequent patient history- questions nurse should ask

-continue to gather data - • Adjustment of the support person and of other children, if any, in the family • Preparations the family has made for the new baby • Discomfort, especially the kinds of discomfort that are often seen at specific times during a pregnancy • Physical changes that relate directly to the pregnancy, such as fetal movement • Exposure to contagious illnesses • Medical treatments and therapies prescribed for nonpregnancy problems since the last visit • Consumption of prescription or over-the-counter medications or herbal supplements that were not prescribed as part of the woman's prenatal care • Use of complementary and alternative therapies • Danger signs of pregnancy and signs of preterm labor

assessment of pelvic adequacy: pelvic cavity (midpelvis)

-evaluation of adequacy is made based on the prominence of the ischial spines and degree of convergence of the side walls. -when sacrospinous ligament felt, examiner should run the fingers along it laterally toward the anterior portion of the pelvis. -The sacrosciatic notch should admit two fingers. A wide notch means that the sacrum curves posteriorly, giving the anteroposterior diameter of the midpelvis a greater length. -The capacity of the cavity can be assessed by sweeping the fingers down the side walls bilaterally to evaluate the shape of the pelvic side walls. They may be termed convergent (closer together at the outlet than the inlet, like a funnel), divergent (side walls farther apart at the outlet), or straight (normal finding). - examiner estimates the hollowness of the sacrum. A flat or shallow sacrum has less room; a hollow sacrum is considered normal.

pregnant risk factor screening

-findings that have been shown to have a negative effect on pregnancy outcomes either for the woman or her unborn child. - identified during the initial prenatal assessment, detected during subsequent visits through subjective and objective data collection. -The nurse needs to be aware of potential risk factors and the impact that they might have on the pregnancy. - initial risk assessment should occur prior to pregnancy when changes can be made to decrease risks during pregnancy. -perinatal health team needs to evaluate psychosocial factors, including ethnic background, occupation, education, financial status, environment, including living arrangements and location, and the woman's and her family's concept of health

Initial Prenatal Assessment

-focuses on the woman holistically by considering physical, cultural, and psychosocial factors that influence her health. - the nurse discusses with the woman any religious, cultural, or socioeconomic factors that may influence the woman's expectations of the childbearing experience. - After the history is obtained, the nurse prepares the woman for the physical examination. -Before the examination, the woman should provide a clean urine specimen for screening. -the assessment guide is organized into three columns that address the areas to be assessed, the variations or alterations that may be observed, and nursing responses to the data.

Assessment of pelvic adequacy - pelvic inlet

-important anteroposterior diameters of the inlet for childbearing are the diagonal conjugate, the obstetric conjugate, and the conjugata vera, or true conjugate -To measure the diagonal conjugate, the distance from the lower border of the symphysis pubis to the sacral promontory, the examiner inserts a gloved hand into the vagina with index and middle finger extended; thumb remains outside; measured by marking the place where the proximal part of the hand makes contact with the pubis -obstetric conjugate is the smallest and thus the most important anteroposterior diameter through which the fetus must pass. It extends from the middle of the sacral promontory to the upper inner point on the symphysis; measured by xray

Obtaining data

-nurses use standardized questionnaires to obtain the necessary data for the initial prenatal visit. -The nurse can review the questionnaire and obtain further information in a direct interview with the patient. -initial interview provides the nurse and the woman the opportunity to begin developing a healthy relationship. -expectant partner should be encouraged to attend the initial and subsequent prenatal visits.

Subsequent Prenatal Assessment

-provides a systematic approach to the regular physical examinations the pregnant woman should undergo for optimal prenatal care -The woman's individual needs and the assessment of her risks should determine the frequency of subsequent visits.

determination of due date

-refer to the due date as the estimated date of birth (EDB) -To calculate EDB, it is essential to know the first day of the woman's LMP. - LMP is sometimes not known because some women have episodes of irregular bleeding or amenorrhea or they may fail to keep track of their menstrual cycles. -An early ultrasound should be obtained if a precise LMP is not available to help establish an accurate EDB. or evaluating uterine size, know when quickening occurs, using early ultrasound, auscultating fetal heart rate with a doppler device or ultrasound

gestation

The number of weeks since the first day of the last menstrual period (LMP).

antepartum

Time between conception and onset of labor, usually used to describe the period during which a woman is pregnant; used interchangeably with prenatal.

postpartum

Time from birth until the woman's body returns to an essentially prepregnant condition, typically about 6 weeks.

intrapartum

Time from onset of labor until the birth of the infant and placenta.

personal information about woman (social history)

• Age. • Relationship status. (Married? Birth father involved? Partner's level of involvement [if partner is not the birth father]?) • Educational level; methods by which she learns best. • Race or ethnic group (to identify need for prenatal genetic screening or counseling). • Housing; stability of living conditions. • Economic level. • Any history of emotional or physical deprivation or abuse of herself or children. (Does she experience any abuse in her current relationship? Has she been hit, slapped, kicked, or hurt within the past year or since she has been pregnant? Is she afraid of her partner or anyone else? If yes, of whom is she afraid?) Note: Ask these questions when the woman is alone. • History of emotional/mental health disorder (depression in general, postpartum depression, anxiety). • Support systems • Personal preferences about the birth (expectations of both the woman and her partner, presence of others, and so on). • Plans for care of child following birth; plans for circumcision if the infant is male. • Feeding method for the baby (breast milk, formula, or both).

genetic history

• Birth defects. • Recurrent pregnancy loss. • Stillbirth. • Down syndrome, mental retardation, developmental delay, chromosomal abnormalities. • Ethnic background (Mediterranean, Jewish, Asian, etc.). • Genetic disorders (cystic fibrosis, sickle cell disease/trait, muscular dystrophy)

past medical history

• Childhood diseases (varicella). • Past treatment for any disease condition. Any hospitalizations? Major accidents? • Surgical procedures. • Presence of bleeding disorders or tendencies. • Blood transfusion history? Will she accept blood transfusion?

Gynecologic History

• Date of last Pap smear; result? History of abnormal Pap results? Colposcopy? Loop electrosurgical excision procedure (LEEP)? Human papilloma virus (HPV)? • Previous infections: vaginal, cervical, pelvic inflammatory disease (PID), sexually transmitted. • Previous surgery (uterine, ovarian). • Age of menarche. • Regularity, frequency, and duration of menstrual flow. • History of dysmenorrhea. • History of infertility. • Sexual history. • Contraceptive history. (If hormonal method was used, did pregnancy immediately follow cessation of method? If not, how long after? When was contraception last used?)

religious/cultural history

• Does the woman wish to specify a religious preference on her chart? Does she have any spiritual beliefs or practices that might influence her health care or that of her child, such as prohibition against receiving blood products, dietary considerations, or other practices? • What practices are important to maintain her spiritual well-being? • Are there practices in her culture or that of her partner that might influence her care or that of her child?

recommended frequency of prenatal visits

• Every 4 weeks for the first 28 weeks of gestation • Every 2 weeks until 36 weeks' gestation • After week 36, every week until childbirth

quadruple screen test results may indicate:

• Higher than normal AFP levels might indicate an increased risk of a fetal neural tube defect, a multiple gestation, or a pregnancy that is farther along than believed. • Lower than normal AFP could indicate that the woman is at risk of having a baby with Down syndrome or trisomy 18. • Higher than normal levels of hCG and inhibin-A and lower than normal UE may also indicate that a woman is at increased risk of having a baby with Down syndrome.

past pregnancies

• Number of pregnancies. • Number of abortions, spontaneous or therapeutic. • Number of living children. • History of previous pregnancies: length of pregnancy, length of labor and birth, type of birth (vaginal, forceps or vacuum-assisted birth, cesarean), location of birth, type of anesthesia/medication used (if any), woman's perception of the experience, complications (antepartum, intrapartum, postpartum). • Neonatal status of previous children: Apgar scores, birth weights, general development, complications, feeding method (breast, formula, or both). If breastfed, how long? • Loss of a child (miscarriage, elective or medically indicated abortion, stillbirth, neonatal death, relinquishment, death after the neonatal period). Cause of loss? What was the experience like for her? What coping skills helped? How did her partner, if involved, respond? • Blood type and Rh factor. (If Rh negative, was Rh immune globulin received after birth/miscarriage/abortion?) • Prenatal education classes, resources (books, websites); knowledge about pregnancy, childbirth, and parenting.

Fundus assessment inaccuracy

• Obese women (because of difficulty palpating the fundus accurately) • Women with uterine fibroids (because uterine size may be distorted) • Women who develop hydramnios (because the excess fluid increases uterine size, leading the examiner to conclude the fetus is larger than it is)

father's/partner social history

• Occupation. • Educational level; methods by which he or she learns best. • Current tobacco use, drug use, and alcohol intake • Thoughts/feelings regarding pregnancy.

occupational history

• Occupation. • Physical demands. (Does she stand all day, or are there opportunities to sit and elevate her legs? Does she do any heavy lifting?) • Exposure to lead, chemicals, or other harmful substances. • Opportunity for regular meals and breaks for nutritious snacks. • Provision for maternity or family leave.

Signs of preterm labor

• Painful menstrual-like cramps • Dull low backache • Suprapubic pain or pressure • Pelvic pressure or heaviness • Change in character or amount of vaginal discharge (bloody, thinner, thicker) • Diarrhea • Uterine contractions felt every 10 minutes for 1 hour • Leaking of water from vagina

family medical history

• Presence of diabetes, cardiovascular disease, hypertension, hematologic disorders, tuberculosis, thyroid disease. • Occurrence of multiple births. • History of congenital diseases or deformities. • History of mental illness. • Occurrence of cesarean births and cause, if known. • Cause of death of deceased parents or siblings.

birth father's physical history

• Presence of genetic conditions or diseases in him or in his family history. • Age. • Significant health problems. • Blood type and Rh factor.

when is nagele's rule not useful

• Women with markedly irregular periods that include 1 or more months of amenorrhea • Women who have amenorrhea but are ovulating and conceive while breastfeeding • Women who conceive before regular menstruation is established following discontinuation of oral contraceptives or termination of a pregnancy