prenatal assessment

8/3/2019 Prenatal Assessment

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PRENATAL ASSESSMENT:

GUIDELINES FOR ASSESSMENT AND CARE OF THE PREGNANT WOMAN

INTRODUCTION

The major goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother. There are

several components involved in achieving this objective:

y Early, accurate estimation of gestational agey Identification of the patient at risk for complicationsy Ongoing evaluation of the health status of both mother and fetusy Anticipation of problems and intervention, if possible, to prevent or minimize morbidityy Patient education and communication

INITIAL PRENATAL VISIT: Key Points

y Provide time for a longer office visit, for example, 45 minutes

y Have patient come in early & complete paper work

y Help patient feel comfortable

y Begin interview with patient fully clothed

y Sit down & make eye contact

y First visit is preferred at 6 weeks gestation (6-8 weeks)

THOROUGH MEDICAL HISTORY: Key points

y Important, as with any initial health care visit

y

Attitudes can indicate future parent-child relationship risk factors:

y How does the patient feel about the pregnancy?

y Was the pregnancy planned

y Underlying medical problems need to be identified, especially:

y Diabetes


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y Hypertension

y Renal disease

y Hemoglobinopathy

y Isoimmunization

y STDs

y Significant other infections

y All components ofPMH are important, especially

y Age

y Last pelvic exam and pap smear

y

Menstrual history

y Previous pregnancies, abortions, miscarriages, deliveries

y Birth control (methods used)

y Fertility infertility issues

y Anesthesia issues or reactions

y Pelvic injury

y Medications: prescription, OTC & complimentary therapies

y Allergies reactions

y Emphasize need to communicate all

medications considered during pregnancy

y Social & home environment influences

y Life-style issues: diet, exercise, sleep, drugs, alcohol, smoking

y ROS: pre-pregnancy weights & baselines

COMMON SYMPTOMS OF PREGNANCY TO CONSIDER: Key points


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y Amennorrhea:

y Results from high levels of hormones:

estrogen, progesterone & hCG (human chorionic gonadotropin)

y Currently used pregnancy tests are based on amount of hCG in

blood or urine, with hCG present as early as 8days after fertilization

y Depending on the specific test used, concentrated urine improves

pregnancy detection rate of urine to equal that of serum testing

y Test may be positive as early as 3-4 days after implantation

y

98% of test results are positive within 7 days after implantation

y Nausea or morning sickness of pregnancy:

y Most common between 8-14 weeks gestation

y Hypersensitivity to odors may develop

y Severe vomiting may result in dehydration or ketosis

y Breast Changes:

y Increased tenderness

y Increased vascularity & sense of heaviness

y

Nipples more erectile, with increased pigmentation

y Raised Montgomerys tubercles on areola

y Colostrum secreted by 16th

week


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y Heartburn:

y Relaxation of gastroesophageal sphincter

y Upward displacement of stomach due to uterine enlargement

y Digestions delays, due to decreases in gastric mobility & gastric acid

y Backache:

y

Increased hormone secretions (estrogen & progesterone)

y Increased pelvic relaxation

y Loss of abdominal muscle tone

y Increased uterine weight

Abdominal Enlargement:

y Uterus rises out of pelvis into abdomen by 12th

week of gestation

y Quickening:

y Usually felt at 20 weeks in primigravida, but earlier in multipara

y Skin Changes:

y Hyperpigmentation


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y Linea alba darkens to linea nigra

y Chloasma pigmentation of face

y Stretch Marks or striae gravidarum

y Nail changes increased grooving, brittleness or softening

y Increased sweating

y Hirsutism

y Urinary Changes:

y

Increased frequency due to uterine pressure in early & late pregnancy

y Vaginal Discharge:

y Increased asymptomatic, white, milky cervical mucous & vaginal discharge

y Fatigue:

y Common in early pregnancy

y Headaches:

y Common, especially around 16 20 weeks gestation

y

Other symptoms:

y Varicose veins

y Leg cramps

y Edema of legs & hands

y Constipation


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y Bleeding gums

y Insomnia

y Dizziness

THOROUGH PHYSICAL EXAMINATION

y Objectives:

y Evaluate health of mother & fetus

y Determine gestational age of fetus

y Initial plan of care

y Measurements & Vital Signs:

y Height & Weight

y Baseline vital signs & BP

y Skin changes: choasma of face

y Teeth & Gums: check for hypertrophy of gums (increased vascularity)

y Thyroid: symmetrical enlargement (R/O goiter)

y Heart & Lungs: (In later stages of pregnancy):

y PMI elevated & lateral in 3rd

trimester


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y Non-pathological systolic flow murmurs develop

Diastolic murmur is always pathological

y Breasts & Nipples: Note expected changes

y Everted nipples indicate possible interference with breast feeding

y Discrete masses are considered pathological

y Abdomen:

y

Contour

y Skin changes: linea nigra, striae gravidarum

y Fetal movement (felt by 24 weeks)

y Uterine size & fundal height

y Fetal Heart Rate (FHR): (120-160 per minute)

Fetal Heart Tones audible with Doppler, from 11-13 weeks gestation

y Genitalia


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y External genitalia & anus: lesions & varicosities

y Vaginal leukorrhea

y Adenexal areas: corpus luteum cyst-like enlargment

y Bimanual & pelvic measurements

COMMON SIGNS OF EARLY PREGNANCY

Sign Finding Gestational Age

Goodell softening of cervix 4-6 weeks

Hegar softening of uterine isthmus 6-8 weeks

McDonald fundus flexes easily on cervix 7-8 weeks

Chadwick bluish color or cervix,

Vagina & vulva 8-12 weeks

y Extremities:

y Varicosities

y Edema

INITIAL DISCUSSIONS WITH PATIENT

y Expected weight gain

y Ideal: 25-30 pounds total


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y 2 pounds per month: 1st

& 2nd

trimester

y 1 pound per week average: last trimester

y Exercise and activity levels

y Varies with physical conditioning of patient

y Contact sports not recommended

y Core temperature elevations about 101.5 may be harmful to fetus

y Diet

y Prenatal appointment schedule:

y Monthly: up to 32 weeks gestation

y Every 2 weeks from 32 to 36 weeks

y Every week from 36 to 40 weeks

y Expected changes of pregnancy & selected important things to know

y PrenatalVitamins:

y Maternal ingestion of 0.4 0.8 mg of Folic Acid per day reduces the

occurrence of fetal neuronal tube defect

y

Most prenatal vitamins contain 1 mg of folic acid

y Prenatal vitamins with folic acid are often recommended

for non-pregnant women of child-bearing age who are planning pregnancy


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y Calculating the Due Date or Expected Date of Confinement (EDC)

Last menstrual period (LMP)

LMP less 3 months

Add 1 year + 7 days = EDC

Or

Nageles Rule:

LMP

Add 9 months + 7 days = EDC

y A Prenatal Flow Sheet for recording visits is through & efficient

MILESTONE LABORATORY TESTS


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y Routine, mandatory: completed at first visit

CBC: detects anemia, hemoglobinopathies, infections

UA: baseline for protein, glucose: r/o

diabetes, renal disease, hypertensive disease of

pregnancy

ABO & Rh typing checks compatibility of maternal-fetal blood types

& need for Rhogam

Rubella titer determine presence or absence of maternal

Antibodies (Rubella causes blindness, heart &

hearing abnormalities in fetus)

Pap smear Screens for cervical intraepithelial dysplasia or neoplasia

HBsAg Hepatitis B surface antigen. Virus infects fetus,

may cause fetal anomalies

VDRL or RPR: screens for syphilis, which infects fetus, causing

congenital anomalies

y Highly recommended lab screening (not mandatory) at first visit:

STD smears/cultures Gonorrhea, Chlamydia, Herpes

Generally cause eye infections & blindness,

repiratory infections & other infections of

newborns. Active herpes near due date

indicates need for C-section birth

HIV requires permission, and signed informed

consent by patient


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MILESTONE LAB TESTS & PROCEDURES SCHEDULED LATER IN PREGNANCY

y 16-18 Weeks:

Ultrasound: most accurate for dating pregnancy

Not mandatory, but most commonly done

y 17-21 Weeks: (when standardized values for this test are most accurate)

Alpha Fetal Protein (AFP)

Medical-legal point: Important to offer this test, and document that it was offered

It is not mandatory in the sense that the patient can refuse

High levels may indicate neuronal tube defects in the fetus

Low values (not as predictive) may be indicative of trisomy 21 &other trisomy defects

Triple Screen: may be used, and combines the following:

AFP

SerumEstriol

HCG

y 24-28 Weeks:


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50 Gram Glucose Tolerance Test (glucose challenge)

H & H: may repeat at 28 weeks (especially with anemia)

y 28-36 Weeks

Beta Hemolytic Streptococcus Screen

Collect culture swabs from vaginal introitus (not cervix)

If positive, mother must be treated before delivery to prevent fetal sepsis

EVERY OB VISIT

Monitor:

y weight, BP temp,

y UA for protein & glucose (dip stick UA),

Lower renal threshold in pregnancy

2+ or greater UA protein could signal pregnancy induced hypertension (PIH)

y Serum glucose screen

y Fundal height: measured from top of pubic bone to top of uterine fundus

Measurement is most accurate from 20-36 weeks gestation

Each 1 cm increase indicates one additional week of gestation

y Edema: dependent edema from pressure on inferior vena cava & iliac veins

y Nausea & vomiting: most prominent from 8-14 weeks gestation


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y Pain & contractions

y Fetal movements

Discuss this at 16 weeks & ask patient to record when fetal movements are felt

(usually between 17-18 weeks)

y Bleeding or discharge

y Recent illness & concerns

MEASURING UTERINE SIZE

y Nulliparous uterus: golf ball size

y 8 weeks gestation (or if second baby): hand ball size

y 10 weeks: baseball size

y 12 weeks: soft ball size

Palpable just above symphysis pubis

y 12-14 weeks: uterus rises up into abdominal cavity

y 16 weeks: fundus palpable halfway between

symphysis & umbilicus

y 20 weeks: fundus at umbilicus (lower border)

y 28 weeks: fundus halfway between umbilicus & xiphoid

y 34 weeks: fundus just below xiphoid

y 38-40 weeks : fundus drops (lightening)


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MILESTONES TO MONITOR ON SUBSEQUENT OB VISITS

y Fetus:

y FHT with Doppler: 12 weeks

y Quickening: 16-19 weeks

(ask patient to keep track of movements)

y Primipara (later, about 18-19 weeks)

y Multipara (sooner, about 16 weeks)

16-18 Weeks:

y Ultrasound

y OfferAFP or Triple Screen: 17-21 weeks

y 24-28 Weeks:

y 50 Gm Glucose Tolerance Test (glucose challenge)

y May repeat H&H at 28 weeks (anemia vs hemodilution)

y Rhogam given if Rh negative

y 32 Weeks:

y Encourage to enroll in Lamaze classes

y 36 Weeks:

y Talk about when to go to the hospital

y What to do if water breaks

y Mucous plug

y Analgesia, anesthesia, epidural


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Pelvis outlet is heart shaped & pubic arch is narrow

Anticipated delivery could be vaginal with forceps or cesarean

y Anthropoid (24% of women):

Pelvic outlet is vertically oval & pubic arch is narrow

Anticipated delivery is vaginal, possible forceps

y Platypelloid (3% of women):

Pelvic outlet is transversely oval & pubic arch is wide

Anticipated delivery is vaginal, sponanteous

y Diagonal conjugate

y One of the most import measurements ofAP diameter of pelvic inlet

y 12.5 13 cm measurement from the inferior border of the symphysis

pubis to sacral promontory

y

Obstetric conjugate

y Also measured the AP diameter of the pelvic inlet, more accurately

obtained by x-ray

y Diagonal conjugate minus 1.5 2 cms from the posterior board of

The symphysis pubis to the sacral promontory

y Angle of pubic arch or subpubic arch

y Estimation of angle of subpubic arch is done by using both

thumbs, & examiner externally traces descending rami down to


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ischia tuberosities

y A wide pubic arch (105 degrees or more) accommodates spontaneous

vaginal delivery

y A narrow pubic arch (less than 90 degrees) indicates a more difficult

Delivery, with use of forceps or suction, or a cesarean section

y Coccyx

y When palpated during bimanual examination, a prominent

inward pointing coccyx could indicate possible problems with

vaginal delivery

COMMON CLINICAL URGENT PATHOLOGICAL CONDITIONS

y

First trimester bleeding: consider normal implantation of ovum,

cervicitis, vaginal varicosities, threatened

abortion (ectopic pregnancy, especially with

abdominal pain)

y Second semester bleeding: abruptio placenta or placenta previa

y Postpartum hemmorage: blood loss over 500 ml during first

24 hours after delivery

y Pseudocesis: false pregnancy (psychiatric considerations)


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Prenatal care (also known as antenatal care) refers to the medical and nursing care recommended for women beforeand during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if

possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to

appropriate specialists, hospitals, etc. if necessary. The availability of routine prenatal care has played a part in

reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable infant

problems. Animal studies indicate that mothers' (and possibly fathers') diet, vitamin intake, and glucose levels priortoovulation and conception have long-term effects on fetal growth and adolescent and adult disease. [1]

While availability of prenatal care has considerable personal health and social benefits, socioeconomic problemsprevent its universal adoption in many developed as well as developing nations.

One prenatal practice is for the expecting mother to consume vitamins with at least 400 mcg of folic acid to help

prevent neural tube defects.

Prenatal care generally consists of:

y monthly visits during the first two trimesters (from week 128)y biweekly from 28 to week 36 of pregnancyy weekly after week 36 (delivery at week 3840)y Assessment of parental needs and family dynamic

Contents

[hide]

y 1 Physical examinationy 2 Ultrasoundy 3 Prenatal Care and Race in the USA

o 3.1 Consequences of Minorities Limited Access to Prenatal Careo 3.2 Prenatal Care and the Latina Paradoxo 3.3 Prenatal Care Improvements for Minorities

y4 References

y 5 External Links

[edit] Physical examination

Physical examinations generally consist of:

y Collection of (mother's) medical historyy Checking (mother's) blood pressurey (Mother's) height and weighty Pelvic examy Doppler fetal heart rate monitoringy (Mother's) blood and urine testsy Discussion with caregiver

[edit] Ultrasound

Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20.

Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy.

Among other things, ultrasounds are used to:


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Prenatal care (also known as antenatal care) refers to the medical and nursing care recommended for women beforeand during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if

possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to

appropriate specialists, hospitals, etc. if necessary. The availability of routine prenatal care has played a part in

reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable infant

problems. Animal studies indicate that mothers' (and possibly fathers') diet, vitamin intake, and glucose levels priortoovulation and conception have long-term effects on fetal growth and adolescent and adult disease. [1]

While availability of prenatal care has considerable personal health and social benefits, socioeconomic problemsprevent its universal adoption in many developed as well as developing nations.

One prenatal practice is for the expecting mother to consume vitamins with at least 400 mcg of folic acid to help

prevent neural tube defects.

Prenatal care generally consists of:

y monthly visits during the first two trimesters (from week 128)y biweekly from 28 to week 36 of pregnancyy weekly after week 36 (delivery at week 3840)y Assessment of parental needs and family dynamic

Contents

[hide]

y 1 Physical examinationy 2 Ultrasoundy 3 Prenatal Care and Race in the USA

o 3.1 Consequences of Minorities Limited Access to Prenatal Careo 3.2 Prenatal Care and the Latina Paradoxo 3.3 Prenatal Care Improvements for Minorities

y4 References

y 5 External Links

[edit] Physical examination

Physical examinations generally consist of:

y Collection of (mother's) medical historyy Checking (mother's) blood pressurey (Mother's) height and weighty Pelvic examy Doppler fetal heart rate monitoringy (Mother's) blood and urine testsy Discussion with caregiver

[edit] Ultrasound

Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20.

Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy.

Among other things, ultrasounds are used to:


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y Diagnose pregnancy (uncommon)y Check for multiple fetusesy Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy

condition)

y Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)y Determine if an intrauterine growth retardation condition existsy Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones)y Check the amniotic fluid and umbilical cord for possible problemsy Determine due date (based on measurements and relative developmental progress)

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:

y 7 weeks confirm pregnancy, ensure that it's neither molar or ectopic, determine due datey 1314 weeks (some areas) evaluate the possibility of Down Syndromey 1820 weeks see the expanded list abovey 34 weeks (some areas) evaluate size, verify placental position

[edit] Prenatal Care and Race in the USA

Many health professionals consider prenatal care a nearly essential practice for pregnant women; however, there are

wide gaps in the American population regarding who has access to these services and who actually utilizes theseservices. For example, African-American expectant mothers are 2.8 times as likely as non-Hispanic white mothers to

begin their prenatal care in the third trimester, or to receive no prenatal care during the entirety of the pregnancy.[2]

Similarly, Hispanic expectant mothers are 2.5 times as likely as non-Hispanic white mothers to begin their prenatalcare in the third trimester, or to receive no prenatal care at all. [3] The following factors impact a womans likelihood of

acquiring prenatal care:

y Health Insurance: 13% of women who become pregnant every year in the United States are uninsured,resulting in severely limited access to prenatal care. According to Childrens Defense Funds website, Almostone in every four pregnant Black women and more than one in three pregnant Latina women is uninsured,compared with one in nearly seven pregnant White women. Without coverage, Black and Latina mothers are

less likely to access or afford prenatal care.[4] Currently, pregnancy is considered a pre-existing condition,

making it much harder for uninsured pregnant women to actually be able to afford private health insurance. [5]

y Formal Education: Oftentimes, Black and Hispanic pregnant women have fewer years of formal education,which sparks a large domino effect of consequences related to prenatal care. A lack of formal education results

in less knowledge about pregnancy appropriate prenatal healthcare as a whole, fewer job opportunities, and a

lower level of income throughout their adult life. [6]

y Trust & Comfort with Healthcare Industry: Many minority women have limited experience with the healthcareindustry on a whole, as compared to their Caucasian counterparts. Consequently, there is a lower level of trustwith physicians, nurses, and the entire care regimen. Many women who are distrustful of biomedicine willdecline certain prenatal tests, citing their own bodily knowledge as more trustworthy than their doctors high-

tech interpretations.[7]Even worse, some minority women may opt to avoid the distress and discomfort of the

medical industry and refuse prenatal care entirely.[8]

y UnderstandingofPrenatalTesting: Many ethnic/racial minority mothers are referred to genetic counselingand prenatal testing centers after being declared at-risk for birth defects after initial screenings. However,

few testing centers effectively communicate what occurs during the various tests, what the test is looking for,

or what the various results could mean for the remainder of the pregnancy. Therefore, some mothers are quiteuncomfortable with this lack of clearly communicated information and are consequently hesitant to pursue

prenatal testing and counseling that health professionals would consider recommendable.[9]

prenatal assessment

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