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Assessment of the Pregnant Woman Anna H. Kelley MSN, ARNP, WHNP-BC Clinical Assistant Professor Assessment of the Pregnant Woman • Assessment begins with a thorough Health history including the following: • Menstrual History • Gynecological History • Obstetrical History • Current Pregnancy • Medical History • Family History • Review of Systems • Nutritional History • Environmental Assessment Menstrual History • Age at Menarche (first menstrual period). • Number of days in cycle. • First day of your last menstrual period (LMP) This is the first day of bleeding with your last cycle. • Was this a normal period for you in terms of length, amount of flow, presence of cramping, timing, and presence of premenstrual symptoms. Calculating EDD using Naegele’s rule • The expected date of delivery (EDD) should be 280 days from LMP. LMP Add 7 days Subtract 3 months Plus one year Naegele’s Rule Calculation • Suppose a woman’s LMP was January 21, 2013. Calculate her estimated date of delivery (EDD) using Naegele’s rule. LMP 1-21-13 Plus 7 days 1-28-13 Minus 3 months 10-28-13 Plus one year 10-28-14 EDD 10-28-14 Naegele’s Rule Calculation A woman’s LMP is June 20, 2014 Calculate her EDD using Nagele’s rule Answer • Her EDD is 3-27-15 . • This calculation is based on the presumption all women have a 28 day cycle and thus ovulation would occur on day 14 of the cycle. Using this calculation 90% of women will deliver within 3 weeks of their EDD, 21% within 3 days and approximately 4% will deliver on their EDD. • Use Naegele’s rule as an estimate. Gynecological History • History of reproductive surgery • History of genital herpes • Last PAP smear, history of abnormal PAP findings and biopsy or follow-up intervention • History of infertility or any uterine abnormalities. • History of sexually transmitted infections (STI) and/or pelvic inflammatory disease (PID). • History of breast disorders/breast surgery Obstetrical History Gravida/Parity History of high risk conditions in pregnancy Personal experience in previous pregnancies/deliveries. Type of previous delivery: vaginal, vaginal assisted, CSection, or VBAC Infertility/ART Previous history of PTL/PTD History of cervical insufficiency/incompetent cervix Gestational age and weights of infants at birth History of breastfeeding and personal satisfaction with method of infant feeding Gravida Includes current and past pregnancies • Gravida: woman who is pregnant • Gravidity: pregnancy • Primigravida: woman who is pregnant for the first time. • Multigravida : a woman who has had two or more pregnancies • Nulligravida: a woman who has never been pregnant Para/Parity • Parity: number of pregnancies in which the fetus(s) have reached viability. • Viability : Ability to survive outside the uterine cavity ( 22-24 weeks after LMP). • Nullipara: woman who has not completed a pregnancy with a fetus(s) reaching viability. • Primipara: woman who has completed one pregnancy with fetus(s) reaching viability. • Multipara: woman who has completed two or more pregnancies to viability. Parity Systems Can be written as two number system G/P or Can be written as a four number system G/FPAL F=# of full term deliveries (38-42 weeks) GA Multi-gestational pregnancies count as 1 delivery P=# of pre-term deliveries(20-37 weeks) GA A=# of abortions or miscarriages (SAB, EAB, TAB) Refers to deliveries prior to 20 weeks gestation L=# of living children Calculating G/P Ally Gator visits your prenatal clinic today for her first prenatal appointment. She states her LMP was approximately 6 weeks ago and states she had a positive home pregnancy test two weeks ago. She states her first pregnancy she delivered twins at 34 weeks gestation and both are living. She states prior to her twins she had a miscarriage at 10 weeks of pregnancy. Calculate G/P using the four number parity system. Answer G 3 P 0-1-1-2 This is her third pregnancy. She has no full term deliveries, one pre-term delivery (34 weeks) of twins, one spontaneous abortion or miscarriage, and has two living children ( the twins). Parity • Note: Parity is not changed immediately after a delivery but rather 28 days following delivery so a primigravida who delivers a full term infant today is still considered a G1/P0 when she is discharged from the hospital. She is considered a G1/P1 or G1 P 1-0-0-1 after 28 days. Current pregnancy • Previous method of contraception-discontinuation date. • Planned pregnancy? Feelings about pregnancy? Support of FOB? Support group. • History of symptoms since pregnant: vaginal bleeding, N/V, abdominal pain, visual changes, edema, frequency/burning on urination, vaginal discharge, or others. • History of recent illness. • Cats in the home. • Fetal Movement? • Plans for breastfeeding? Medical History • • • • • • • • • • Allergies: Medications and other items Personal or family history of cancer History of asthma and intervention History of German measles or chicken pox or immunization date for each History of back injury Testing for HIV: date and result. High risk activities. Tobacco, alcohol or recreational drug use Medications: prescribed, OTC, or herbal Exercise program History of Vitamin D deficiency Family History • • • • • • • Hypertension Diabetes Mental illness including depression Kidney disease Fraternal twins Congenital anomalies Racial or Ethnic descent: Mediterranean, African American, Jewish and Irish Review of Systems • • • • • • • • • Pre-pregnant weight Visual issues/glasses/contacts Dental issues/screenings/x-rays Exposure to tuberculosis (TB)/date of last PPD Cardiovascular disease Anemia History of thrombophlebitis/PE/DVT History of hypertension or renal disease History of Hepatitis, Thyroid disease, Seizures, Urinary tract infections, or Diabetes. • History of Depression/Mental illness • Screening for Domestic Violence Nutrition • Vegetarian or special diets • Food intolerance Environmental Hazards • Occupation • Physical demands of work • Exposure to strong odors, chemicals, and radiation. • Adequate food and housing • Use of seatbelt when driving General Survey • Observe grooming, posture, mood and affect View Maternal Child Nursing Care textbook Perry, Hockenberry, Lowdermilk and Wilson page 225 for pictures of postural changes during pregnancy. • Assessment and recording of weight • Observe for Lordosis in last trimester of pregnancy • Clean catch urinalysis specimen for evaluation • Ask if patient has concerns/questions that require answering • If gestational age is greater than 16 weeks as about presence of fetal movement (FM) • Ask about presence of edema, headache, visual symptoms, burning /frequency of urination, N/V, vaginal bleeding or discharge. • Assessment and recording of Blood pressure Skin • Assessment of skin including presence of scars indicative of previous reproductive surgery including C-Section. • Some skin changes during pregnancy including acne and skin tags will generally resolve after pregnancy. • Presence of Chloasma ( the mask of pregnancy), Linea nigra (hyper pigmented line extending from sternum to symphysis pubis) and striae (stretch marks). Linea Nigra Striae “Stretch Marks” Mouth and Neck • Mucous membranes pink and moist • Gum hypertrophy (pregnancy gingivitis) may be present • Bleeding gums ( estrogen stimulation) Encourage dental hygiene and soft toothbrush • Thyroid may feel full but should be smooth unless disease is present Pregnancy Gingivitis Breasts • Breasts enlarge and may be tender to palpation. • Areola and nipples enlarge and become darker in pigmentation. The nipples may become more erect. • Blood vessels of the breasts enlarge and can be visualized easily through seemingly transparent skin. • Montgomery tubercles located around areola enlarge. • Colostrum may be secreted as early as week 14 and may be expressed from the nipples. • Breast tissue feels nodular. Important for the pregnant woman to continue her breast self examinations during pregnancy. Breast Changes in Pregnancy Heart and Lungs • Pregnancy often produces a functional, soft, blowing systolic murmur as the result of increased blood volume. The murmur requires no treatment and will resolve after pregnancy. • The lungs should be clear to auscultation bilaterally without evidence of crackles or wheezing. Shortness of breath may be present in the third trimester and occurs from pressure on the diaphragm from the enlarging uterus. Peripheral Vasculature and Neurologic • Legs may show bilateral pitting edema in the third trimester especially if the woman is on her feet for a prolonged period of time. • Varicose veins are common in the third trimester. • Homan’s Sign is negative bilaterally • Assess biceps and patellar deep tendon reflexes (DTR). Normally these are 1+ to 2+ and equal bilaterally. Abdomen • As the woman in supine position lifts her head you may see separation of the diastasis recti abdominal muscles. These will return together after pregnancy with the use of abdominal exercise. • The fundus (top of the uterus) will be palpable abdominally after 12 weeks gestation. • Obtain measurement of Fundal height after 20 weeks gestation. Measuring Fundal Height • With the woman in supine position using a measuring tape with recording in centimeters, measure from symphysis pubis to fundus. After 20 weeks of gestation the number of centimeters should be approximately equal to the number of weeks gestation. Leopold’s Maneuvers • Leopold’s Maneuvers are an abdominal assessment which give you information about the placement of the fetus in utero. There are four maneuvers involved in this assessment. First Maneuver • Used to determine the fetal part located in the fundus. The examiner faces the patient’s head and places their fingertips around the top of the fundus. The fetal head will feel large, round and firm in comparison to the buttocks which will feel softer in comparison. Second Maneuver • Moving your hands to the sides of the uterus note whether small parts ( arms, hands, legs and feet) are palpable or whether you feel the long firm surface of the back. • Assessment of fetal heart tones ( the fetal heartbeat) is best detected through the back or shoulder. Third Maneuver • Have the woman bend her knees slightly and palpate the lower abdomen just above the symphysis pubis between the thumb and fingers of one hand to determine the fetal part present in the lower segment of the uterus. Fourth Maneuver • Assists in determining engagement and to differentiate a shoulder from the head. The most difficult maneuver for a novice nurse to perform. In this maneuver the examiner faces the patients feet as they press on either side of the lower abdomen. Auscultation of Fetal Heart Tones • Fetal heart tones are a positive sign of pregnancy. They can be heard by Doppler around 10-12 weeks of gestation. FHT’s are best heard through the back or shoulder of the fetus. Count for a full minute if possible. Normal rate is between 110160 beats per minute. Accelerations of heart rate are common with fetal movement and indicate fetal well being. • Differentiate the FHT’s from the slower maternal pulse or heart rate. Watch Fetal Assessment Video http://www.youtube.com/watch?v=nIog3oizP8A Pelvic Examination/Speculum examination • Assess genitalia: labial enlargement and varicosities may be present. Presence of vaginal discharge /unusual odor warrants further investigation. • Chadwick’s sign is the bluish/purplish discoloration of the vaginal walls and cervix due to increased vascularity and engorgement of pregnancy. Cervical Os • Cervical os is round or dot like in a nulliparous woman and looks like a transverse slit or crooked line in a woman who has given birth vaginally before. • Refer to Maternal Child Nursing Care Textbook Perry, Hockenberry, Lowdermilk and Wilson page 214 Figure 10-2 for pictures showing comparison of cervix in nullipara and multipara woman. Bimanual examination/Pelvimetry • Hegar’s sign • Goodell’s sign • Assessment of pelvic shape: Gynecoid, Android, Anthropoid or Platypelloid will give an examiner and indication of how favorable the bony structure of the pelvis is for a vaginal delivery. Questions • Provide a time to answer patients questions. • If you have questions related to the content of this lecture please send me an email at [email protected] and I will respond to the entire class.