The Prenatal Assessment

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Chapter 9

• The Prenatal Assessment

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CAREing for the Patient (Prenatal Period)

• Nurses role
• Communicate
• Advocate
• Respect
• Empower women
• Help woman become informed recipient of care
• Facilitate shared decision-making

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Stress and Pregnancy

• Nurses role
• Focus on communication, personalized care,
  education
• Provide support
• Offer stress management techniques
• Gain womans confidence

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Healthy People 2011

• Access to care
• Barriers to service
• Health insurance
• Health provider barriers
• System barriers
• Social disparities

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The First Prenatal Visit
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Nurses RoleFirst Prenatal Visit

• Build positive, nonthreatening relationship
• Therapeutic communication
• Avoid medical/technical jargon
• Provide user-friendly service
• Goal to explain purpose of prenatal care to
  establish specific goals

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Comprehensive Health History

• Biographical data
• Social historyintimate partner violence and drug
  use
• Psychological assessment
• Obstetric history
• Current pregnancy

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Signs and Symptoms of Pregnancy

• Presumptive
• Amenorrhea
• Nausea/vomiting
• Urinary frequency
• Breast tenderness

• Probable
• Piskacek sign uterine asymmetry with a soft
  prominence on the implantation side
• Hegar sign softening of the lower uterine
  segment
• Chadwick sign violet bluish color of the vaginal
  mucosa and cervix

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Positive Signs of Pregnancy

• Fetal heartbeat
• Fetal movements
• Visualization of fetus

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Estimated date of birth (EDB)

• Naegeles rule add 7 days, then subtract 3
  months from the date of the last normal menstrual
  period
• History
• Intercourse/signs and symptoms
• Date of last normal menstrual period

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Pregnancy Classification System

• Gravid/gravida/gravidity
• Nulligravida never experience pregnancy
• Primigravida pregnant for the first time
• Multigravida pregnant for the third time
• Parity number of pregnancies carried to
  viability age

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Pregnancy Classification System

• GTPAL classification system
• G- gravida
• T- number of Term pregnancies
• P- number of preterm deliveries
• A- abortions both spontaneous and induced
• L- number of living children

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Medical History

• Medical conditions
• Dental health
• Eye health
• Immunizations
• Hepatitis B infection

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Gynecological History

• Environmental hazards
• Teratogens
• DES exposure diethylstilbestrol (nonsteroidal)
• TORCH
• Breast surgery/cancer/lumps/biopsies
• History of rape, abuse

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Gynecological History

• Infertility
• Surgeries
• Therapeutic/elective pregnancy terminations
• History of STIs
• Cervical pathology

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Homework 1 Based on this diagram, develop your
concept map on how to provide prenatal care to a
client who came in for her first prenatal visit.
2. Write up of Changes of pregnancy by system
tests.
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Screening and Diagnostic Tests

• Screening
• Rh factor, antibody screen
• Sexually transmitted infections
• HIV
• Cervical cancer
• Diagnostic
• To confirm presence of disease

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Prenatal Physical Examination

• Prepare patient and environment
• Obtain consent to be examined
• Ongoing interaction
• General assessment
• Nutritional assessment
• Abdominal palpation

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FUNDAL HEIGHT MEASUREMENT
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Leopold Maneuvers

• First determine fetal body part that occupies
  uterine fundus
• Second determine location of fetal spine
• Third compare fundus with lower uterine segment
• Fourth determine ballottement engagement

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Preparation

• Instruct woman to empty her bladder first.
• Place woman in dorsal recumbent position, supine
  with knees flexed to relax abdominal muscles.
  Place a small pillow under the head for comfort.
• Drape properly to maintain privacy.
• Explain procedure to the patient.
• Warms hands by rubbing together. (Cold hands can
  stimulate uterine contractions).
• Use the palm for palpation not the fingers.

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First Maneuver

• Purpose
• First Maneuver To determine fetal part lying in
  the fundus.
• To determine
  presentation.
• Procedure
• Using both hands, feel for the fetal part lying
  in the fundus.
• Head is more firm, hard and round that moves
  independently of the body.
• Breech is less well defined that moves only in
  conjunction with the body.

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PRESENTATION
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Second Maneuver

• Purpose To identify location of fetal back. To
  determine position.
• Procedure
• One hand is used to steady the uterus on one side
  of the abdomen while the other hand moves
  slightly on a circular motion from top to the
  lower segment of the uterus to feel for the fetal
  back and small fetal parts.

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Second Maneuver

• Use gentle but deep pressure
• Fetal back is smooth, hard, and resistant
  surfaceKnees and elbows of fetus feel with a
  number of angular nodulation

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Third Maneuver

• Purpose
• To determine engagement of presenting part.
• Procedure
• Using thumb and finger, grasp the lower portion
  of the abdomen above symphysis pubis, press in
  slightly and make gentle movements from side to
  side.
• Findings
• The presenting part is engaged if it is not
  movable.
• It is not yet engaged if it is still movable.

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Fourth Maneuver

• Purpose
• To determine the degree of flexion of fetal head.
• To determine attitude or habitus.
• Procedure
• Facing foot part of the woman, palpate fetal
  head pressing downward.Use both hands.

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Leopold Maneuvers
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Fetal Heart Auscultation

• 120 to 160 beats per minute
• Fetoscope
• Doppler ultrasound stethoscope
• Electronic fetal monitoring for high-risk
  pregnancies
• Non-stress test

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Subsequent Prenatal Examinations

• Maternal weight gain/edema
• Blood pressure
• Urine
• Uterine growth
• Fetal heart tones
• Fetal movements and presentation

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Assessing Special Populations
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Teenage Pregnancy

• Nurses role
• Heighten public awareness
• Empower women/families to reduce unwanted
  pregnancies
• Advocate for responsible sexual behavior
• Impact on society

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• Teen pregnancy accounts for more than 9 billion
  per year in costs to U.S. taxpayers for increased
  health care and foster care, increased
  incarceration rates among children of teen
  parents, and lost tax revenue because of lower
  educational attainment and income among teen
  mothers.4
• Pregnancy and birth are significant contributors
  to high school drop out rates among girls.
• The children of teenage mothers are more likely
  to have lower school achievement and drop out of
  high school, have more health problems, be
  incarcerated at some time during adolescence,
  give birth as a teenager, and face unemployment
  as a young adult.

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Nursing Care of Pregnant Adolescent

• Assessment
• Closely monitor for iron deficiency anemia, STIs,
  preeclampsia
• High-risk behaviors
• Knowledge regarding personal care and care of
  infant
• Promote optimal nutrition
• OB Exam 1 (covers week 1 lecture Changes of
  Pregnancy)