Dr. Areefa Al Bahri

Chapter 3

The Prenatal Assessment

Introduction Introduction The objective of this chapter is to enhance understanding of the complexities and challenges involved in providing prenatal nursing care. Each prenatal visit offers an opportunity for the nurse to provide a comforting, supportive environment for the expectant woman and her family members. During these visits, educational needs can can be discussed, reassurance can be provided, and problems or potential problems can be discovered.

Promoting maternal physical, psychological, and spiritual health and facilitating maternal empowerment are key to promoting and enhancing fetal well-being and a positive pregnancy outcome. throughout pregnancy are explored.

Goals that guide nursing careof the prenatal patient

•To recognize deviations from normal• To provide individualized, evidence-based care• To provide culturally appropriate prenatal educationdesigned to meet the patient’s learning style and needs• To empower women to become actively involved in their pregnancy by being informed recipients and shared decision makers.

Despite tremendous improvements in perinatal care, women still die in childbirth and it is not unrealistic for a woman to fear for her own safety. The World Health Report “Make Every Woman and Every Child Count” (World Health Organization 2005) focuses on making pregnancy safer and asserts that reaching this goal centers on providing excellent antenatal care and constructing societies that support pregnant women. Antenatal care must be consistently accessible and responsive while incorporating patient-centered interventions, thereby removing barriers that prevent access to care.

Prenatal Visit timePrenatal Visit time

Prenatal care usually begins in the first trimester of pregnancy, when the patient is seen every 4 weeks until she reaches 28 to 32 weeks’ gestation. At that time, the appointments are changed to visits every 2 weeks and then occur weekly from 36 weeks of gestation until birth.

Although this schedule has to some extent become the “standard of care,” it has not been possible to substantiate the necessity for such frequent visits. Interestingly, the number of total prenatal visits varies tremendously from as few as 3 to 4 visits (less number) for low-risk women in some European countries to 14 or more visits for women with uncomplicated pregnancies in the United States (Partridge & Holman, 2005).

CARE PrinciplesCommunicationThe exchange of information by speaking, writing, or using a common system of signs or behavior or written messageAdvocateOne who argues for a cause; a supporter or defenderOne who pleads in another’s behalf; Advocates for abused children and spousesRespectTo show consideration or thoughtfulness in relation to somebody or somethingEnableTo provide somebody with the resources, authority, or opportunity to do something To make something .

Choosing a Pregnancy Care Choosing a Pregnancy Care ProviderProvider

One of the early decisions the patient (and partner) makes concerns choosing a care provider.

It is recommended that every patient arrange an appointment with a chosen care provider (obstetrician, family practice physician, certified nurse midwife) to discuss the management of pregnancy and childbirth as early as possible within the first trimester.

The woman may seek childbearing care from an obstetrician, a family practice physician, or a certified nurse midwife. Approximately 90% of pregnant women choose anobstetrician as the primary care provider.

The First Prenatal Visit

The Comprehensive Health HistoryComprehensive Obstetrics history Biographical DataSocial HistoryPsychological Assessment

Presumptive Signs Of Pregnancy

The subjective signs of pregnancy are the symptoms that the patient experiences and reports. Because these symptoms may be caused by other conditions, they are the least indicative of pregnancy. In combination with other pregnancy symptoms, the following presumptive signs may serve as diagnostic clues:1.Amenorrhea2.Nausea and vomiting (morning sickness)3.Frequent urination4.Breast tenderness5.Perception of fetal movement (quickening)6.Skin changes(striae gravidarum)7.Fatigue

PROBABLE SIGNS OF PREGNANCY

1. Abdominal enlargement 2. Hegar sign (softening of the lower uterine segment) may also

be caused by pelvic congestion.3. Goodell sign may also be caused by infection, hormonal

imbalance or pelvic congestion.4. Chadwick may also be caused by pelvic congestion, infection,

or a hormonal imbalance.5. Braxton–Hicks sign also be associated with uterine

leiomyomas (fibroids) or other tumors.6. Positive pregnancy test may occur from certain medications,

premature menopause, choriocarcinoma 7. Ballottement may be due to uterine tumors or cervical polyps

instead of the presence of a fetus.

The positive indicators of pregnancy are attributable only to the presence of a fetus:

1. Fetal heartbeat2.Visualization of the fetus3. Fetal movements palpated by the examiner

positive signs of pregnancy

Naegele’s Rule is used to calculate the Expected Date of Birth (EDB) – Expected Date of Delivery (EDD) This calculation is based on the first day of the woman’s last normal period. 7 days are added to the LMP and 3 months subtracted and where necessary a year added.

The Pregnancy Classification System

Gravidity: relates to the number of times that a woman has been pregnant, irrespective of the outcome. nulligravida :a woman who has never experienced a pregnancy. primigravida: is a woman pregnant for the first time. A multigravida: pregnant for the third (or more times). Parity: pregnancies carried to a point of viability (500 gat birth or 20 weeks of gestation), regardless of the outcome.For example, “para 1” indicates that one pregnancy reachedthe age of viability. It is important to note that the term parity (or “para”) denotes the number of pregnancies, not the number of fetuses/babies, and does not reflect whether the fetuses/babies were born alive or stillborn.Some facilities use a digital system (i.e., GTPAL) for recording the number of pregnancies and their outcomes.

G GravidaT Number of Term pregnanciesP Number of Preterm deliveriesA Number of Abortions, both spontaneous and inducedL Number of Living children

The Prenatal Physical Examination

The patient should be given adequate private time to preparefor the examination and encouraged to void if needed (a urine specimen may also need to be collected). Before conducting the physical examination, it is essential to properly prepare the environment. The room should be warm, with a cover for the patient and a gown for her to wear. Ensure privacy for the patient, such as a “Do not disturb exam in progress” sign affixed to the closed door.

Abdominal Palpation for Abdominal Palpation for Fetal PositionFetal Position

PurposePurpose

1.1. Determine the Determine the positionposition of of the baby in utero the baby in utero

2.2. Determine the Determine the expected expected presentationpresentation during labor during labor and delivery and delivery

Questions to ask yourself when performing Questions to ask yourself when performing the abdominal palpation examination:the abdominal palpation examination:

1.1. Is the fundal height consistent with the fetal Is the fundal height consistent with the fetal maturity?maturity?

2.2. Is the, transvelie longitudinalrse or oblique?Is the, transvelie longitudinalrse or oblique?

3.3. Is the presentation cephalic or breech? Is the presentation cephalic or breech?

4.4. If cephalic, is the attitude vertex or facial? If cephalic, is the attitude vertex or facial?

5.5. What is the position of the denominator? What is the position of the denominator?

6.6. Is the vertex engaged?Is the vertex engaged?

The fetal The fetal lielie is either: is either:

LongitudinalLongitudinalo long axis of the fetus is alligned to the mother’slong axis of the fetus is alligned to the mother’so this is the only NORMAL positionthis is the only NORMAL position

TransverseTransverseo long axis of the fetus is perpendicular to that of the long axis of the fetus is perpendicular to that of the

mother’smother’s ObliqueOblique

o long axis of the fetus is 0-90 degrees (or 90-180 long axis of the fetus is 0-90 degrees (or 90-180 degrees) to that of the mother’sdegrees) to that of the mother’s

Fetal LieFetal Lie

The The presentationpresentation is either: is either:

VertexVertexo head down in the pelvishead down in the pelvis

BrowBrow FacialFacial

Breech Breech o head is up in the uterine head is up in the uterine

fundus and the buttocks is fundus and the buttocks is down in the pelvisdown in the pelvis

ShoulderShoulder

AttitudeAttitude

The attitude is the relationship of the fetal parts to each other:

o Flexed o Deflexed o Extended

EngagementEngagement

Determined by the amount of head that is Determined by the amount of head that is above or below the pelvic brimabove or below the pelvic brim

o This is usually done by dividing the head This is usually done by dividing the head into ”fifths”into ”fifths”o if the head is still palpable abdominally, it is if the head is still palpable abdominally, it is

“2/5” or less engaged“2/5” or less engaged

Leopold’s ManeuverLeopold’s Maneuver

PURPOSESPURPOSES To provide information about fetal To provide information about fetal

presentation, position, presenting part i.e. lie, presentation, position, presenting part i.e. lie, attitude, and descentattitude, and descent

To aid in location of fetal heart ratesTo aid in location of fetal heart rates

To aid in assessment of fetal sizeTo aid in assessment of fetal size

To determination of single versus multiple To determination of single versus multiple gestationgestation

Leopold’s Leopold’s ManeuverManeuver

Four-part process Four-part process

Palpation of fetal Palpation of fetal position in-uteroposition in-utero

PreparationPreparation

Woman is supine, head slightly elevated and Woman is supine, head slightly elevated and knees slightly flexedknees slightly flexed

Place a small rolled towel under her right hipPlace a small rolled towel under her right hip

If the nurse is R handed, stand at the woman’s R If the nurse is R handed, stand at the woman’s R side facing her for the first 3 steps, then turn and side facing her for the first 3 steps, then turn and face her feet for the last step (L handed, left side).face her feet for the last step (L handed, left side).

First ManeuverFirst Maneuver

Facing the mother, palpate theFacing the mother, palpate thefundus with both handsfundus with both hands– Assess for shape, size, consistency and mobilityAssess for shape, size, consistency and mobility

Fetal head: firm, hard, and roundFetal head: firm, hard, and round– Moves independently of the restMoves independently of the rest– Detectable by ballotementDetectable by ballotement

Breech/buttocks: softer and has bony Breech/buttocks: softer and has bony prominencesprominences– Moves with the rest of the formMoves with the rest of the form

Second ManeuverSecond ManeuverDetermine position of the back.Determine position of the back.

Still facing the mother, place both palms on the Still facing the mother, place both palms on the abdomenabdomeno Hold R hand still and with deep but gentle pressure, Hold R hand still and with deep but gentle pressure,

use L hand to feel for the use L hand to feel for the firm, smooth back firm, smooth back o Repeat using opposite handsRepeat using opposite hands

Confirm your findings by palpating the fetal Confirm your findings by palpating the fetal extremities on the opposite side extremities on the opposite side o small protrusions, “lumpy”small protrusions, “lumpy”

Third ManeuverThird Maneuver

Determine what part is lyingDetermine what part is lying

above the inlet.above the inlet.

Gently grasp the lower portion of the abdomen Gently grasp the lower portion of the abdomen (just above symphisis pubis) with the thumb and (just above symphisis pubis) with the thumb and fingers of the R hand fingers of the R hand

Confirm presenting part Confirm presenting part

(opposite of what’s in the fundus)(opposite of what’s in the fundus)

Head will feel firmHead will feel firm Buttocks will feel softer and irregularButtocks will feel softer and irregular

If it’s not engaged, it may be gently If it’s not engaged, it may be gently pushed back and forthpushed back and forth

Proceed to the 4Proceed to the 4thth step if it’s not step if it’s not engaged…engaged…

Fourth ManeuverFourth Maneuver

1.1. Locate brow.Locate brow.2.2. Assess descent of the presenting part.Assess descent of the presenting part.

Turn to face the woman’s feetTurn to face the woman’s feet Move fingers of both hands gently down Move fingers of both hands gently down

the sides of the abdomen towards the the sides of the abdomen towards the pubis pubis

- Palpate for the cephalic prominence (vertex)- Palpate for the cephalic prominence (vertex)

Fourth Maneuver (cont’d)Fourth Maneuver (cont’d) Prominence on the same side as the small parts Prominence on the same side as the small parts

suggests that the head is flexed (optimum)suggests that the head is flexed (optimum)

Prominence on the same side as the back suggests Prominence on the same side as the back suggests that the head is extendedthat the head is extended