Assessment Admission
❖ Birth imminence❖ Fetal status ❖ Maternal status ❖ Risk assessment
Tips If a woman presents with ℅ bleeding ask her how man sanitary napkins she has saturated in an hour.
Assessment of reproductive history Gravida: Number of pregnancies the woman has had regardless of outcome Nulligravida: never been pregnantMultigravida: more than one pregnancyParity: the client communicates outcome of previous pregnanciesGTPAL : G: Gravida – the total number of pregnancies regardless of outcome T: Term – the number of pregnancies that ended at term (at or beyond 38 weeks’ gestation) P: Preterm – the number of pregnancies that ended after 20 weeks and before the end of 37 weeks’ gestation either A : Abortions – the number of pregnancies that ended before 20 weeks’ gestation either spontaneous or inducedL: Living – the number of children delivered who are alive when the history is taken
Components of assessment Obstetric History
❖ Number and outcomes of previous pregnancies in GTPAL (gravida, term, preterm, abortions, living) format (see Chapter 7 for a detailed explanation of these terms)
❖ Estimated delivery date❖ History of prenatal care for current pregnancy❖ Complications during pregnancy❖ Dates and results of fetal surveillance studies, such
as ultrasound or nonstress test (NST)❖ Childbirth preparation classes❖ Previous labor and birth experiences
Current Labor Status❖ Time of contraction onset❖ Contraction pattern including frequency, duration,
and intensity❖ Status of membranes❖ Description of bloody show or bleeding❖ Fetal movements during the past 24 hours
Medical–Surgical History❖ Chronic illnesses❖ Current medications❖ Prescribed❖ Over-the-counter❖ Herbal remedies
Social History❖ Marital status❖ Support system❖ Domestic violence screen❖ Cultural/religious considerations that affect care❖ Amount of smoking during pregnancy❖ Drug and alcohol use during pregnancy
Desires/Plans for Labor and Birth❖ Presence of a partner, coach, and/or doula (see
Chapter 7 for discussion of doulas)❖ Pain management preferences❖ Other personal preferences affecting intrapartum
nursing care❖ Presence of a birth plan❖ Desires/Plans for Newborn❖ Plans for feeding—breast or formula❖ Choice of pediatrician❖ Circumcision preference, if the infant is male❖ Rooming-in preference (Hatfield 208)
Prenatal visits Ist visit : ❖ Family History, Medical Surgical History,
Social History, Teaching, Avoiding teratogenic, substance ingestion, Alcohol, tobacco, illegal drugs, etc., Diet, nutrition, and exercise, Infection control
❖ Medication use ❖ Determining due dates ❖ Naegele's rule❖ Add seven days to the date of the first day of
the LMP, then subtract three months (and add a year)
❖ Pelvic examination❖ Practitioner sizes the uterus to estimate term❖ Obstetric sonogram: High frequency sound
waves reflect off fetal and maternal pelvic structures, allowing structure measurement
