- age of viability
- conjugate vera
- diagonal conjugate
- ischial tuberosity
- lithotomy position
- true conjugate
- Describe the areas of health assessment commonly included in prenatal visits.
- Assess a pregnant woman's health status.
- Formulate nursing diagnoses related to health status of pregnancy.
- Identify expected outcomes for achieving a healthy pregnancy.
- Plan nursing care such as preparing a woman for a pelvic examination or fundal measurement.
- Implement nursing care such as establishing a risk score for pregnancy.
- Evaluate outcomes related to fetal or maternal health to measure for the achievement and effectiveness of care.
- Identify National Health Goals nurses can help the nation achieve.
- Identify areas of prenatal care that could benefit from additional nursing research or application of evidence-based practice.
- Use critical thinking to analyze ways to ensure family-centered prenatal care.
- Integrate knowledge of pregnancy health assessment with nursing process to achieve quality maternal and child health care.
- Increase to at least 80% the proportion of primary care providers who provide age-appropriate preconception care and counseling.
- Increase to at least 90% the proportion of all pregnant women who receive prenatal care in the first trimester of pregnancy from a baseline of 76% (DHHS, 2000).
- Decisional conflict related to desire to be pregnant
- Risk for ineffective coping related to confirmation of unplanned pregnancy
- Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy
- Deficient knowledge regarding exposure to teratogens during pregnancy
- Risk for injury to fetus related to current lifestyle behaviors
- Establish a baseline of present health
- Determine the gestational age of the fetus
- Monitor fetal development
- Identify women at risk for complications
- Minimize the risk of possible complications by anticipating and preventing problems before they occur
- Provide time for education about pregnancy, lactation and newborn care
- Couple states they have reached a decision about maintaining or discontinuing the pregnancy.
- Client states she feels well informed about the common discomforts of pregnancy and actions to take to relieve them.
- Client lists ways to avoid exposure to teratogens during pregnancy.
- Describe factors to consider when deciding about pregnancy
- Describe components of a healthy pregnancy, including healthy diet, appropriate rest and exercise, and potential adverse effects of alcohol, tobacco, and drug use
- Identify maternal risk factors associated with pregnancy and fetal development, environmental hazards, and risk for hereditary diseases
- Describe potential personal and family adjustments to pregnancy and addition of new family member
- Obtaining client history, including thorough sexual history, and determining readiness for pregnancy with both partners
- Providing information about risk factors
- Referring for genetic counseling or prenatal diagnostic testing as needed
- Encouraging dental examination to minimize exposure to x-ray examinations and anesthetics
- Instructing about the relationships among early fetal development and personal habits, medication use, teratogens, and self-care needs
- Recommending self-care measures needed during the preconception period
- Educating about ways to avoid teratogens
- Discussing ways to prepare for pregnancy socially, financially, and psychologically
- Identifying real and perceived barriers to obtaining family planning services
- Encouraging contraception until prepared for pregnancy
- Discussing methods of identifying fertility, signs of pregnancy, and ways to confirm pregnancy
- Emphasizing the need for early and continued prenatal care once pregnant
discussing more intimate things (her feelings toward this pregnancy, the difficulty she has reworking old fears, how scared she is about birth).
- Establishing rapport
- Gaining information about the woman's physical and psychosocial health
- Obtaining a basis for anticipatory guidance for the pregnancy
test or used a home test kit. Elicit information about the signs of early pregnancy, such as nausea, vomiting, breast changes, or fatigue. Question her about any discomforts of pregnancy, such as constipation, backache, or frequent urination. Also, ask about any danger signs of pregnancy, such as bleeding, continuous headache, visual disturbances, or swelling of the hands and face.
- Schedule appointments for women within a week after they first call the health care setting. This initial contact can be done through a group orientation session, individually by a health team member, or, if risk status warrants, by a physician. Try to schedule further appointments at times convenient for the client and her support people to encourage attendance.
- Make waiting time educational by providing materials such as pamphlets or videotapes in the waiting room.
- Provide privacy for assessments such as blood pressure, weight, and urine checks.
- Encourage women to feel responsible for their health record. If a woman's first language is not English, make sure to record pregnancy information so she can read it.
- Be certain that pregnant women meet health care providers while fully clothed and upright, not naked and in a lithotomy position on an examining table.
- Encourage family members and friends to accompany the woman for prenatal care. Allow them to enter the examination room and participate in all aspects of care to the extent they and the client desire.
- Schedule appointments to provide continuity of care. Be certain that women have a specific person's name as a phone or e-mail contact for pregnancy-related questions. Without this information, they tend not to call.
- Educate pregnant women about care options and encourage them to participate in making decisions about their care.
- Acknowledgment of the importance of prenatal care and prenatal education along with discussion of options for providing prenatal health care and childbirth
- Identification of the danger signs of pregnancy and possible complications
- Description of the following: major fetal developmental milestones; physical and psychological changes of pregnancy; appropriate health-promotion behaviors such as proper body mechanics, adequate rest and sleep, and exercise; measures to promote self-care for discomforts of pregnancy; healthy weight gain patterns and correct use of dietary supplements; importance of dental care; safer sex practices; and proper use of safety devices in an automobile
- Description of the signs of labor and techniques to facilitate effective labor
- Identification of possible fetal teratogens and environmental hazards
- Discussion of ways to prepare family members
- Instructing client on importance of regular prenatal care throughout pregnancy, necessary nutrition, exercise, rest, desired weight gain, danger signs, fetal growth and development, self-care strategies for common discomforts, and harmful effects of teratogens
- Encouraging client's partner to participate in prenatal care, including attending prenatal classes
- Monitoring physiologic parameters including nutritional status, blood pressure, laboratory studies such as urine glucose and protein and hemoglobin, edema of ankles, hands and face, deep tendon reflexes
- Measuring fundal height with comparison to gestational age
- Assessing fetal heart rate and fetal growth and development
- Providing anticipatory guidance about physical and psychological changes during pregnancy
- Monitoring psychological adjustment of client and family, along with counseling client about changes in sexuality and body image during pregnancy
- Assessing social support system and assisting client to develop and use social support
- Instructing client on how to monitor fetal activity
- Guiding client in imaging her unborn child as appropriate
- Providing parents with opportunity to hear fetal heart tones and see ultrasound image of the fetus
- Referring client to childbirth preparation and child care and parenting classes as appropriate
with her in the coming months about a bedroom or space for a baby's bed. It also is important to know whether the essential rooms are on the ground floor or upstairs in case she is restricted from climbing stairs more than once or twice a day during the last part of pregnancy or after birth.
TABLE 10.1 Gynecologic Disorders
- Was it planned?
- Did she have any complications, such as spotting, swelling of her hands or feet, falls, or surgery?
- Did she take any medication? If so, what and why?
- Did she receive prenatal care? If so, when did she start?
- What was the duration of the pregnancy?
- What was the duration of labor?
- Was labor what she expected? Worse? Better?
- What was the type of birth?
- What type of anesthesia, if any, was used?
- Did she have stitches following birth?
- Did she have any complications, such as excessive bleeding or infection following the birth?
- What was the infant's birthweight and sex?
- What was the condition of the infant at birth? Did the infant cry right away?
- What was the infant's Apgar score? (Most mothers know this.)
- Was any special care needed for the baby, such as suctioning, oxygen, or an incubator?
- Was the baby discharged from the health care setting with her?
- What is the child's present state of health?
- How was the pregnancy overall for her?
- T: The number of full-term infants born (infants born at 37 weeks or after)
- P: The number of preterm infants born (infants born before 37 weeks)P.253
- A: The number of spontaneous or induced abortions
- L: The number of living children
- M: Multiple pregnancies
TABLE 10.2 Terms Related to Pregnancy Status
- Head: Headache? Head injury? Seizures? Dizziness? Fainting?
- Eyes: Vision? Glasses needed? Diplopia? Infection? Glaucoma? Cataract? Pain? Recent changes?
- Ears: Infection? Discharge? Earache? Hearing loss? Tinnitus? Vertigo?
- Nose: Epistaxis (nose bleeds)? Discharge? How many colds a year? Allergy? Postnasal drainage? Sinus pain?
- Mouth and pharynx: Dentures? Condition of teeth? Toothaches? Any bleeding of gums? Hoarseness? Difficulty in swallowing? Tonsillectomy?
- Neck: Stiffness? Masses?
- Breasts: Lumps? Secretion? Pain? Tenderness?
- Respiratory system: Cough? Wheezing? Asthma? Shortness of breath? Pain? Serious chest illness, such as tuberculosis or pneumonia?
- Cardiovascular system: History of heart murmur? History of heart disease such as rheumatic fever or Kawasaki disease? Hypertension? Any pain? Palpitations? Anemia? Does she know her blood pressure? Has she ever had a blood transfusion?
- Gastrointestinal system: What was her prepregnancy weight? Vomiting? Diarrhea? Constipation? Change in bowel habits? Rectal pruritus? Hemorrhoids? Pain? Ulcer? Gallbladder disease? Hepatitis? Appendicitis?
- Genitourinary system: Urinary tract infection? Hematuria? Frequent urination? Sexually transmitted infection? Pelvic inflammatory disease? Hepatitis B? HIV?
- Extremities: Varicose veins? Pain or stiffness of joints? Any fractures or dislocations?
- Skin: Any rashes? Acne? Psoriasis?
FIGURE 10.1 Include support people in a prenatal visit so that visits are family centered. Here a husband, wife, and child are included in the initial prenatal interview, making all feel a part of the pregnancy. (© Barbara Proud.)
- Ask for appointments to be scheduled at a time that is convenient for both of you.
- Be certain that your partner reserves enough time so the visit doesn't become more of an inconvenience than an enjoyable event. A prenatal visit can be lengthy.
- Ask your partner to accompany you into the examining room at visits so you both can share progress or decisions.
- Be certain that your partner listens to the fetal heart at visits as soon as it can be heard.
- If a sonogram is scheduled, ask your partner to view it with you (it's an exciting moment for both of you to see your fetus moving).
or sparseness of hair suggests poor nutrition. Lack of cleanliness may suggest fatigue, reflecting that the woman has not felt well enough to wash it recently. Urge women during pregnancy to let some other task go and save energy for self-care so they can continue to feel good about themselves. Dandruff shampoos may be used during pregnancy because they are not absorbed.
FIGURE 10.2 A woman weighs in at a prenatal visit. Pregnant women may need reassurance that gaining weight aids fetal growth. (© Barbara Proud.)
- Areolae darken.
- Secondary areolae may develop surrounding the natural ones.
- Montgomery tubercles (sebaceous glands in the areolae) become prominent.
- Overall breast size increases.
- Breast consistency firms.
- Blue streaking of veins becomes prominent.
- Colostrum may be expelled as early as the 16th week of pregnancy.
- Any supernumerary nipple also may become darker and enlarge in size.
abdomen. This position prevents them from developing muscle strains from abnormal abdominal muscle tension. Many pregnant women develop a “waddling” gait late in pregnancy from relaxation of the symphysis pubis. This relaxation may cause pain if the cartilage is actually so unstable that it moves on walking.
FIGURE 10.3 Plotting uterine height on a uterine height graph at prenatal visits (typically after 12 weeks gestation) helps to monitor whether fundal height is adequate.
(on her back with her thighs flexed and her feet resting in the examining table stirrups (see Fig. 10.5). Make sure her buttocks extend slightly beyond the end of the examining table. Place a pillow under her head to help her relax her abdominal muscles.
FIGURE 10.4 Insertion of a vaginal speculum. (A) Blades held obliquely on entering the vagina. (B) Blades rotated to horizontal position as they pass the introitus. (C) Blades separated by depressing thumbpiece and elevating handle. The position of the blades is maintained by adjusting a thumbscrew.
FIGURE 10.5 A lithotomy position used for a pelvic examination. Help position the woman with her buttocks just over the edge of the table. Drape appropriately for modesty.
posterior vaginal wall due to loss of posterior vaginal muscular support) or a cystocele (a pouching of the bladder into the anterior vaginal wall, caused by loss of anterior vaginal muscular support), are also evaluated. To reveal these, while the labia are gently separated to allow a view of the vaginal walls, the woman is asked to bear down as if she were moving her bowels.
FIGURE 10.6 (A) Appearances of the cervix. (1) Nulligravida cervix. (2) Cervix after childbirth. (3) “Stellate” cervix seen after mild cervical tearing. (B) Possible cervical lesions. (1) Herpes II. (2) Chancre of syphilis. (3) Erosion or infection.
to allow the short bristles to contact the endocervix, and it is rotated in a clockwise direction five times. The device is then rinsed off in a special solution-filled collection vial; the vial is then capped, labeled, and sent to the laboratory (Fischbach, 2004; Fig. 10.8).
FIGURE 10.7 Obtaining a traditional Pap smear. (A) Specimen taken from endocervix. (B) Specimen taken from cervix. (C) Specimen taken from vaginal pool.
FIGURE 10.8 For liquid Pap tests, the collecting instrument is placed in a commercial vial and capped rather than being smeared onto a slide.
turns them dark blue to purple. Any areas of inflammation, ulceration, lesions, or discharge should be noted.
TABLE 10.3 Interpretation of Pap Smears (Bethesda System)
FIGURE 10.9 A bimanual examination to determine uterine size.
- The diagonal conjugate. This is the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis (Fig. 10.11A). The most useful measurement for estimation of pelvic size, it suggests the anteroposterior diameter of the pelvic inlet (the narrower diameter at that level, or the one that is most apt to cause a misfit with the fetal head). The diagonal conjugate is measured while the woman is in a lithotomy position. To measure it, two fingers are introduced vaginally and pressed inward and upward until the middle finger touches the sacral prominence. With the other hand, the part of the examining hand where it touches the symphysis pubis is marked (see Fig. 10.11A). After withdrawing the examining hand, the distance between the tip of the middle finger and the marked point on the glove on that hand is measured by comparing it with a ruler or, for greater accuracy, a pelvimeter. Caution the client that the measurement may be slightly painful, because she may feel the pressure of the examining finger as it stretches to touch the sacral prominence. If the examiner's hand is small with short fingers, manual pelvic measurements may not be possible, because the fingers may not reach the sacral prominence. If the measurement obtained is more than 12.5 cm, the pelvic inlet is rated as adequate for childbirth (the diameter of the fetal head that must pass that point averages 9 cm in diameter).
- The true conjugate or conjugate vera is the measurement between the anterior surface of the sacral prominence and the posterior surface of the inferior margin of the symphysis pubis. This measurement cannot be made directly, but it can be estimated from the measurement made of the diagonal conjugate. To do this, the usual depth of the symphysis pubis (assumed to be 1.5 to 2 cm) is subtracted from the diagonal conjugate measurement. The distance remaining will be theP.264
true conjugate, or the actual diameter of the pelvic inlet through which the fetal head must pass. The average true conjugate diameter is, therefore, 12.5 cm minus 1.5 or 2 cm, or 10.5 to 11 cm.
- The ischial tuberosity diameter. This measurement is the distance between the ischial tuberosities, or the transverse diameter of the outlet (the narrowest diameter at that level, or the one most apt to cause a misfit). It is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus (see Fig. 10.11B). A pelvimeter is generally used, although the diameter can be measured by a ruler or by comparing it with a known hand span or clenched fist measurement. A diameter of 11 cm is considered adequate because it will allow the widest diameter of the fetal head, or 9 cm, to pass freely through the outlet.
FIGURE 10.10 Types of pelves. (A) Android pelvis—“male” pelvis. The pubic arch in this pelvis type forms an acute angle, making the lower dimensions of the pelvis extremely narrow. A fetus may have difficulty exiting from this type of pelvis. (B) Anthropoid pelvis—“ape-like” pelvis. The transverse diameter is narrow, and the anteroposterior diameter of the inlet is larger than normal. This structure does not accommodate a fetal head as well as a gynecoid pelvis. (C) Gynecoid pelvis—“normal” female pelvis. The inlet is well rounded forward and backward; the pubic arch is wide. This pelvic type is ideal for childbirth. (D) Platypelloid pelvis—“flattened” pelvis. The inlet is an oval, smoothly curved, but the anteroposterior diameter is shallow. A fetal head might not be able to rotate to match the curves of the pelvic cavity in this type of pelvis.
- A complete blood count, including hemoglobin or hematocrit and red cell index to determine the presence of anemia, a white blood cell count to determine infection, and a platelet count to estimate clotting ability.
- Women are advised to have a blood sample taken for a genetic screen for commonly ethnically inherited diseases. African-American women mayP.265
have a blood sample taken to screen for sickle cell trait or disease and possibly glucose-6-phosphate dehydrogenase. Asian and Mediterranean women may have this done for beta-thalassemia; those with Jewish ancestry may have this done for Tay-Sachs disease, and Caucasian women may be tested for cystic fibrosis (see Chapter 7 for a discussion of these disorders).
- A serologic test for syphilis (VDRL or rapid plasma reagin test). If syphilis is present, it must be treated early in pregnancy before fetal damage occurs. A blood sample for a serologic test for gonorrhea may be drawn on women suspected of having this disease.
- Blood typing (including Rh factor). Blood type is documented because blood may have to be made available if the woman has bleeding early in her pregnancy.
- Maternal serum for AFP (MSAFP). This level will be elevated if a neural tube or abdominal defect is present in the fetus; it may be decreased if a chromosomal anomaly is present. This test is done at 16 to 18 weeks of pregnancy. The level in serum is expressed as “multiples of the mean” (MOM). A normal value is 2.5 MOM. If this is elevated or decreased, a sonogram or amniocentesis will be ordered to assess for a fetal disorder.
- An indirect Coombs' test (determination if Rh antibodies are present in an Rh-negative woman). This test is generally repeated at 28 weeks of pregnancy. If the titers are not elevated, an Rh-negative woman will receive RhIG (RhoGAM) at 28 weeks of pregnancy and after any procedure that might cause placental bleeding, such as amniocentesis or external version.
- Antibody titers for rubella and hepatitis B (HBsAg). These tests determine whether the woman is protected against rubella if exposure should occur during pregnancy and whether a newborn will have a chance of developing hepatitis B. HBsAg testing may be repeated at about 36 weeks. Antibodies for varicella (chickenpox) may also be assessed. Vaccine against these diseases can be offered in the postpartum period.
- HIV screening. All women can be asked, and those at high risk for contracting HIV infection should be asked, whether they want to be screened for this disease early in pregnancy. High-risk criteria include women who have used or are using intravenous drugs; have engaged in sex with multiple partners; have had sexual partners who are infected or are at risk because they are bisexual, intravenous drug abusers, or hemophiliacs; or received a blood transfusion between 1977 and 1985 (Minkoff & Gibbs, 2003).Screening is done by an enzyme-linked immunosorbent assay (ELISA) on a blood sample. If this is positive, the finding is confirmed by a second test (a Western blot). Testing for HIV early in pregnancy allows a woman who is found to be HIV antibody positive the opportunity to begin therapy with zidovudine (AZT), which can decrease the risk of her infant acquiring the virus. It also allows the woman the option of choosing to terminate a pregnancy to avoid giving birth to an infant who has a high risk of HIV infection.As there is still no cure for HIV infection, some women may choose not to have a blood titer taken because they would rather not know that they have the illness. This is their option. Screening cannot be mandatory in prenatal settings. Health care providers need to be certain that test results given to clients are accurate (a high blood antibody titer means the person has been exposed to the virus, not that he or she necessarily is infected) and are presented with tact and compassion, with respect for the meaning of the results to the client. Results of HIV testing are kept confidential; be certain not to report this information to anyone other than the client.
- If the woman has a history of previously unexplained fetal loss, has a family history of diabetes, has had babies who were large for gestational age (9 lb or more at term), is obese, or has glycosuria, she will need to be scheduled for a 50-g oral 1-hour glucose loading or tolerance test toward the end of the first trimester to rule out gestational diabetes. If not, she will have this done routinely at the 24th to 28th week to evaluate insulin-antagonisticP.266
effects of placental hormones, which can register a noticeable effect at this time. The plasma glucose level should not exceed 140 mg/dL at 1 hour (see Chapter 14 for a discussion of diabetes in pregnancy).
FIGURE 10.11 (A) Measurement of diagonal conjugate diameter. Solid line = diagonal conjugate; dotted line = true conjugate. (B) Measurement of ischial tuberosity diameter.
that would identify a pregnancy as being at high risk. The woman identified this way needs close observation during pregnancy to see that the pregnancy is progressing well; the infant born of a woman identified this way needs close observation in the neonatal period until it is confirmed that no anomalies exist.
TABLE 10.4 Assessments for a First Pregnancy Visit
TABLE 10.5 Assessments That Might Categorize a Pregnancy as At Risk
- Interim history or new personal or family developments since last visit Review danger signs of pregnancy Review symptoms of beginning labor
- Blood pressure (every visit)
- Clean-catch urine for glucose, protein, and leukocytes (every visit)
- Blood serum level for alpha-fetoprotein (MSAFP) (16 weeks)
- VDRL test for syphilis if possibility of new exposure
- Glucose screen (28 weeks)
- Glucose challenge (24 to 28 weeks) if warranted
- Anti-Rh titer (28 weeks)
- Group B streptococcus (GBS) (35 to 37 weeks)
- Fetal heart rate
- Fundal height
- Quickening or fetal movement
- Ultrasound dating of pregnancy
- Prenatal care has the potential to reduce the incidence of preterm birth and congenital anomalies and the infant mortality rate. Its purposes include establishing a baseline of present health, determining the gestational age of the fetus, monitoring fetal development, identifying the woman at risk for complications, minimizing the risk of possible complications by anticipating and preventing problems before they occur, and providing time for education about pregnancy and possible dangers.
- A first prenatal visit confirms a pregnancy, but it is also a time for important assessments such as a health history, physical examination, and laboratory tests. The physical examination could include measurement of fundal height and assessment of fetal heart sounds if the pregnancy is beyond 12 weeks, a pelvic examination (including a Pap test), and possibly an estimation of pelvic size.
- A first prenatal visit sets the tone for visits to follow. Maintaining a supportive manner is helpful in establishing rapport and allowing a woman to feel comfortableP.269
to return for future care. Remember that a family, not a woman alone, is having a baby, and include family members in procedures and health teaching as desired.
- For a pelvic exam, pregnant women should remain in a lithotomy position for as short a time as possible to help prevent thromboembolism and supine hypotension syndrome.
- Common pelvic types include gynecoid (well-rounded with a wide pubic arch), anthropoid (narrow), platypelloid (flattened), and android (male or with a sharp pubic arch). A gynecoid pelvis is ideal for childbearing.
- The true conjugate (conjugate vera) is the measurement between the anterior surface of the sacral prominence and the posterior surface of the inferior margin of the symphysis pubis (the anterior-posterior diameter of the pelvic inlet). The average is 10.5 to 11 cm. The ischial tuberosity diameter is the distance between the ischial tuberosities or the transverse diameter of the outlet. The average is 11 cm.
- Sandra Czerinski, whom you met at the beginning of the chapter, was worried about having a pelvic examination. How could you help relieve her concern?
- Sandra works at a commercial laundry ironing sheets. Is there any type of pregnancy risk for her at this job? Is this a job that probably keeps her on her feet for long periods? Is she apt to be exposed to toxic substances at work? Is there a greater opportunity than usual for her to develop upper respiratory infections?
- Sandra's boyfriend rarely comes with her to prenatal visits. Another woman has a supportive husband who always comes. Would your role be different in these two situations?
- Examine the National Health Goals related to prenatal care. Most government-sponsored money for nursing research is allotted based on these goals. What would be a possible research topic to explore pertinent to these goals that would be applicable to the Czerinski family and also advance evidence-based practice?