Friday, November 19, 2010

Maternal and Child Health Nursing Chapter 10

Chapter 10
Assessing Fetal and Maternal Health: Prenatal Care
Sandra Czerinski is a 29-year-old woman, 16 weeks pregnant, who comes for a first prenatal visit. She is concerned because she didn't realize she was pregnant until a week ago. Because of this, she has been actively dieting (two diet drinks plus one meal of mainly vegetables daily) plus lifting weights at a health club. She says she wants her urine tested because she has to void all the time. She does not want any blood work done because she doesn't have health insurance. She hasn't had a pelvic examination since she was in high school, when she had a vaginal infection. She remembers that exam as being very painful.
Previous chapters described normal anatomy and physiology of the reproductive tract and the changes of pregnancy. This chapter adds information about prenatal care that helps to ensure a healthy outcome for both a woman and her child. This is important information because prenatal care is directly responsible for protecting the health of both women and newborns.
What type of support or counseling does Sandra need?

Prenatal care, essential for ensuring the overall health of newborns and their mothers, is a major strategy for helping to reduce the number of low-birthweight babies born yearly (Wessel, Endrikat, & Buscher, 2003). It is seen as so important that a number of National Health Goals speak directly to it (Box 10.1). Ideally, prenatal care begins during the mother's childhood. It includes balanced nutrition with adequate intake of calcium and vitamin D during infancy and childhood to prevent rickets (which can distort pelvic size); adequate immunizations against contagious diseases for protection against viral diseases such as rubella during pregnancy; and a healthy daily diet to ensure the best state of health possible for a woman and her partner when entering pregnancy.
Promoting prenatal health also includes developing positive attitudes about sexuality, womanhood, and childbearing. Once a woman becomes sexually active, preparation for a successful pregnancy includes practicing safer sex, regular pelvic examinations, and prompt treatment of any sexually transmitted infection to prevent complications that could lead to infertility. Acquisition and use of reproductive life planning information may help to ensure that each pregnancy is planned.
Women who maintain a healthy lifestyle come to a first prenatal visit prepared to follow health-promotion strategies. For many women, this visit may be the first time they have been to a health care facility since the routine health maintenance visits of childhood. It also may be the first time they have had an appointment that focuses more on health promotion than on the diagnosis of disease. A woman may have a specific reason (her agenda) for coming to the first prenatal visit (e.g., to confirm the diagnosis of pregnancy). A prenatal visit is also a time for additional health promotion, pregnancy education, and development of a positive pattern of healthy behaviors for the family to use in the future (your agenda). What and how much is needed varies depending on the age and parity of the woman and her degree of family support.
Health Promotion During Pregnancy
The Preconceptual Visit
Ideally, women schedule appointments with a physician or nurse-midwife before becoming pregnant to obtain accurate reproductive life planning information, receive reassurance about fertility (as much as can be given based on a health history and a routine physical examination), and detect any problems that may need correction through a health history, pelvic examination, and Papanicolaou (Pap) test. At this visit, hemoglobin level and blood type (including Rh factor) can be determined; minor vaginal infections such as those arising from Candida or chlamydia can be corrected to help ensure fertility; and the woman can be counseled on the importance of a good protein diet, adequate intake of folic acid, and early prenatal care if she does become pregnant (Moos, 2004). More often, however, women arriving for their first prenatal visit will not have had a recent health care appointment oriented toward reproduction. Thus, the first prenatal visit usually covers a wide range of assessment criteria. Box 10.2 highlights appropriate outcomes and interventions for preconception care using the terminology identified by the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC).
Choosing a Health Care Provider for Pregnancy and Childbirth
Once a woman is or suspects that she may be pregnant, she chooses a primary health care provider to care for her throughout the pregnancy and birth. Various options are available, including a prenatal clinic, her HMO health care provider, a nurse-midwife, an obstetrician, or a family practitioner. Regardless of the type of health care provider chosen, prenatal care needs to be initiated early and continued throughout pregnancy (Box 10.3).
Nurses can contribute to the success of prenatal care by listening, counseling, and teaching, three areas of nursing expertise. Many clinics and group practices provide an initial educational seminar for women in the early stages of their pregnancy, often led by a nurse or nurse practitioner. Some practices form cohorts of women to meet monthly and discuss their concerns, termed “centered pregnancy care” (McCartney, 2004). Box 10.4 summarizes ways that prenatal care can be improved and individualized so that all women are interested in obtaining it.
Health Assessment During the First Prenatal Visit
Prenatal care is important because lack of it is associated with the birth of preterm infants and various complications for the woman (Villar et al., 2005). The major causes of death during pregnancy today for women are ectopic pregnancy, hypertension, hemorrhage, embolism, infection, and anesthesia-related complications such as intrapartum cardiac arrest (DHHS, 2000). An important focus of all prenatal visits, therefore, is to screen for danger signs that might reveal any of these conditions (see Chapter 11).
Box 10.5 highlights appropriate outcomes and interventions for prenatal care using the terminology identified by the Nursing Outcomes Classification and Nursing Interventions Classification.
The first visit includes an extensive health history, a complete physical examination, including a pelvic examination, and blood and urine specimens for laboratory work. Manual pelvic measurements can be taken to determine pelvic adequacy. Following this, time should be set aside to begin health education about pregnancy (Box 10.6).

The Initial Interview
Interviewing expectant women often elicits contradictory information. Women are likely to want to talk about their past health and current pregnancy, so interviewing them should go smoothly and be productive. On the other hand, pregnancy symptoms are subtle, so a woman may not regard certain information as important, providing vague answers to questions about these areas. Perhaps she is unaware that she is the only person who knows the answers to a number of vital questions (“How do you feel about being pregnant?” or “Have you been taking anything for your morning nausea?”). Outside pressures, such as having to report for work or older children coming home from school, may interfere with the effectiveness of the interview. Late in pregnancy, a woman may feel uncomfortable sitting for a long time.
Interviewing is best accomplished in a private, quiet setting. Trying to talk to a woman in a crowded hallway or a full waiting room is rarely effective. Pregnancy is too private an affair to be discussed under these circumstances.
It is helpful if the person scheduling the appointment cautions a woman that the first visit may be long. This prevents her from trying to fit the visit in between other errands or from having to terminate the interview because of another appointment.
Be certain to ask what name a woman wants you to use when addressing her in a prenatal setting, and make certain that she knows your name and understands your role correctly. If she views you as someone only gathering preliminary data, she will be willing to discuss superficial facts (name, address, phone number, and the like) but will resist

discussing more intimate things (her feelings toward this pregnancy, the difficulty she has reworking old fears, how scared she is about birth).
Because initial health history taking is often time-consuming, a woman may be asked to complete some of the forms. Good interviewing technique, however, is important to obtain thorough and meaningful health histories. The rapport established by face-to-face interviewing gives a woman the feeling that she is more than just a client number or chart. It may be as much a reason she returns for follow-up care as her desire to be assured that her pregnancy is progressing normally.
Components of the Health History
An initial interview serves several purposes:
  • Establishing rapport
  • Gaining information about the woman's physical and psychosocial health
  • Obtaining a basis for anticipatory guidance for the pregnancy
Establishing a baseline health picture at the initial pregnancy visit is important. If on subsequent visits a symptom is mentioned, you can then check your records to verify that it is truly a new symptom. It may be that the woman is just becoming more aware of it. General interviewing techniques are discussed in Chapter 33. Included in the following section are the elements pertinent to a pregnancy history.
Demographic Data
Demographic data usually obtained include name, age, address, telephone number, religion, and health insurance information.
Chief Concern
The chief concern is the reason the woman has come to the health care setting—in this instance, the fact that she is or thinks she is pregnant.
To help confirm pregnancy, inquire about the date of her last menstrual period and whether she has had a 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.
Ask if the pregnancy was planned. If you feel uncomfortable asking directly, using a statement such as, “All pregnancies are a bit of a surprise. Is that how it was with this one?” may help provide you with this information. Another way to word such a question would be, “Some couples plan on having children right away; some plan on waiting. How was it with you?” If the woman says the pregnancy was not planned, explore to learn if she has reached a decision about whether to continue with the pregnancy. A question such as, “Some women change their mind about wanting a baby once they realize they are pregnant; some don't. How has it been for you?” may be effective for obtaining this type of information because it says either option is possible. You just want her to tell you which is happening.
Family Profile
In the past, the social history or family setting history (family profile) was left until the end of a health interview. More often, it is now obtained at the beginning of the interview, following the chief concern. Doing so can help you get to know a woman earlier, identify support persons, shape the nature and kind of questions asked, and evaluate the possible impact of the client's culture on care. Ask about marital status. As a rule, both married and unmarried women want you to know this as they want to alert you if they do not have support people readily available.
It is important to know the size of the apartment or house in which a woman lives because you will be talking



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.
Before you can begin to offer a woman any more than stereotyped health care instruction, get to know her and her sexual partner's age (additional testing such as genetic screening may be necessary if she is over 35), their educational levels (offers an estimation of the level of teaching you will plan), and occupation (does the woman's work involve heavy lifting, long hours of standing in one position, handling of a toxic substance?).
Adaptation to pregnancy is highly individualized. A change in status from independence to dependence because of stopping work, chronic illness at home, the death or loss of a significant person during pregnancy, geographic moves, financial hardship, and lack of support people are examples of situations that can hinder a woman's ability to accept her pregnancy and child. No one in the health care setting will be aware of these potentially harmful situations unless questions about family profile are asked.
History of Past Illnesses
Questions about a woman's past medical history are an important part of an interview because a past condition may become active during or immediately following pregnancy. Representative diseases that can pose a potential difficulty during pregnancy include kidney disease, heart disease (coarctation of the aorta and rheumatic fever cause problems most often), hypertension, sexually transmitted infection (including hepatitis B and human immunodeficiency virus [HIV]), diabetes, thyroid disease, recurrent seizures, gallbladder disease, urinary tract infections, varicosities, phenylketonuria, tuberculosis, and asthma. It is important to find out whether a woman had childhood diseases such as chickenpox (varicella), mumps (epidemic parotitis), measles (rubeola), German measles (rubella), or poliomyelitis. From this information, you can estimate the degree of antibody protection the client has against these diseases if she is exposed to them during her pregnancy. While pregnant, she can be immunized against poliomyelitis by the Salk (killed virus) vaccine. However, she cannot be immunized against the other diseases because the vaccines against these contain live viruses, as does the oral Sabin poliomyelitis vaccine. Live virus vaccines could be harmful to the fetus if the virus crossed the placenta.
Also ask about any allergies, including any drug sensitivities. As a rule, women with allergies of any magnitude should be urged to breast-feed rather than bottle-feed their infants to avoid possible milk allergy in the infant (Hanson, Korotkova, & Telemo, 2003). Any past surgical procedures are also important because adhesions resulting from past abdominal surgery may interfere with uterine growth.
History of Family Illnesses
A family history documents illnesses that occur frequently in the family and helps to identify potential problems in the mother during pregnancy or in the infant at birth. Ask specifically about cardiovascular and renal disease, cognitive impairment, blood disorders, or any known genetically inherited diseases or congenital anomalies (McGregor & Parker, 2003).

Day History/Social Profile
Information about a woman's current nutrition, elimination, sleep, recreation, and interpersonal interactions can be elicited best by asking the woman to describe a typical day of her life. If any of this information is not reported spontaneously as she describes her day, ask for additional details.
Nutrition is an important part of a day history to obtain, particularly in light of the number of young adults with eating disorders today. A “24-hour recall” is helpful to obtain accurate nutrition information because by doing this, the woman tells you what she actually ate, not what she should have eaten (Box 10.7).
Ask about the type, amount, and frequency of exercise to determine her routine pattern and whether it will be consistent with a recommended level for pregnancy. If she hikes or camps, she is at risk for exposure to Lyme disease. Ask about hobbies. Certain hobbies, such as working with lead-based glazes and ceramics, might not be wise to continue during pregnancy because lead is teratogenic.
Because smoke, whether first-hand or second-hand, has been shown to be harmful to fetal growth (Albrecht et al., 2004), obtain information about the client's smoking habits. Excessive alcohol intake can lead to poor nutrition, can be directly responsible for fetal alcohol syndrome, and may cause preterm birth (Albertson et al., 2004). If a woman answers vaguely about how much she smokes or drinks alcohol (“I drink socially” or “I only smoke occasionally”), attempt to determine exactly what she means so you can more accurately evaluate the frequency of these events.
Pregnant women, especially adolescents, are at an increased risk for intimate partner abuse. Ask enough questions to be certain the woman is not involved in an abusive partnership (Katz, 2003).
A medication history is also important. Ask whether the woman takes any medications, prescribed or over-the-counter, because their effect on a growing fetus will have to be evaluated. This also includes any herbal preparations that a woman might be using. Even seemingly innocent medications for simple conditions can be detrimental during pregnancy. For example, isotretinoin (Accutane), a vitamin A preparation taken for acne, is associated with spontaneous miscarriage and congenital anomalies. Herbal supplements should be evaluated carefully before being taken by pregnant women to be certain they don't stimulate uterine contractions (Buehler, 2003).
Ask about the use of any recreational drugs, such as marijuana or cocaine, as these also can be deleterious to fetal growth. Include intravenous drug use because of the increased risk for exposure to HIV or hepatitis B. Although this type of information is not usually readily revealed, most women will answer these questions honestly during pregnancy because they are concerned about protecting the health of their fetus.
Gynecologic History
In the past, most women had children early in their childbearing years, so the number of reproductive tract or women's health problems, such as breast disease, they had experienced before pregnancy were few. Today, however, women often delay conception of their first child past 30 years of age. Therefore, it is not unusual to discover a woman who has had a reproductive tract or breast problem. Table 10.1 lists common gynecologic illnesses and their possible significance in pregnancy.
TABLE 10.1 Gynecologic Disorders
Disorder Possible Symptoms Significance and Suggested Therapy

Cysts of Skene's or Bartholin's glands Asymptomatic swelling at the sides of the urinary meatus or vestibule Such cysts are surgically incised to prevent blockage of gland duct.
Condylomata acuminata Cauliflower-like lesion on vulva This lesion tends to occur in women with chronic vaginitis. Caused by the epidermatrophic virus that causes common warts. Removed by cryocautery or knife excision.
Lichen sclerosus Whitish papules on the vulva; asymptomatic There is no need for removal; the area is biopsied because leukoplakia, a potentially cancerous condition, has an almost identical appearance.
Leukoplakia Thick, gray, patchy epithelium that cracks; possibly a pre-malignant state and infects easily, accompanied by itching and pain Therapy involves hydrocortisone and frequent return visits to health care personnel (every 6 months) for observation to detect any changes suggestive of carcinoma.
Carcinoma of the vulva A shallow vulvar ulcer that does not heal Vulvar cancer occurs most often in postmenopausal women; represents only 3% to 4% of all reproductive tract cancers in women. Therapy is vulvectomy—vagina is left intact, and sexual relations and pregnancy, with cesarean birth to prevent tearing of fibrotic vulvar tissue, may be possible.
Vagina and Cervix

Adenosis Asymptomatic vaginal cysts with columnar rather than squamous epithelium present on vaginal walls This condition is caused by diethylstilbestrol (DES) administration while in utero. Has the potential for becoming malignant (clear cell adenocarcinoma). If adenosis is present, an examination two or three times a year with a Pap test and Lugol's staining is necessary, and the woman should not use estrogen sources such as oral contraceptives. If adenocarcinoma occurs, local destruction of atypical cells can be achieved by excision, cautery, or cryosurgery. This condition is rarely seen today because DES is no longer prescribed during pregnancy.
Cervical polyp Red, vascular, protruding pedunculated tissue that bleeds readily with trauma A polyp may be discovered because of vaginal spotting on coitus, tampon insertion, or vaginal examination. Removed vaginally by excision. Often associated with chronic cervical inflammation.
Cervicitis (erosion) Reddened cervical tissue with a whitish exudate Douching with a vinegar solution aids healing. May be treated with cryosurgery if extensive.
Nabothian cyst Clear shining circles on cervix from blocked gland ducts No therapy is necessary.
Cervical carcinoma Postcoital spotting, unexplained vaginal discharge or spotting between menstrual periods Cervical cancer is the most frequent type of reproductive tract malignancy; risk factors include coitus with multiple partners or uncircumcised males, herpes type II infections, or DES use during pregnancy. Diagnosed by Pap test or colposcopy. Therapy is conization, radiation, or surgical excision. Pregnancy is possible following cervical carcinoma; cesarean birth may be necessary because of fibrotic cervical tissue.

Endometrial cyst Chocolate-brown cyst on tender enlarged ovary; may cause acute pain if rupture occurs Endometriosis is the cause; occurs in women aged 20 to 40 years. Therapy is surgical excision; ovary may or may not be removed depending on extent of cyst.
Follicular cyst Amenorrhea and possibly dyspareunia; ovary tender and enlarged Cysts typically regress after 1 or 2 months; low-dose oral contraceptive may be prescribed for 6 to 12 weeks to suppress ovarian activity; estrogen may be continued for 6 months.
Polycystic disease Multiple follicular cysts of both ovaries Excess adrenal supply of estrogen leads to inhibition of follicle-stimulating hormone and anovulation. Clomiphene citrate therapy to induce ovulation or wedge resection of the ovaries is used as therapy.
Corpus luteum cyst Delayed menstrual flow followed by prolonged bleeding; ovary enlarged and tender A corpus luteum has persisted rather than atrophied. Most regress in about 2 months; a low-dose oral contraceptive may be prescribed for 6 weeks to suppress ovarian activity.
Dermoid cyst Asymptomatic; ovary enlarged on examination Cyst originates from embryonic tissue; may contain hair, cartilage, and fat. Most common ovarian tumor of childhood; also occurs at 30 to 50 years. Therapy is surgical resection.
Serous cystadenoma Bilateral; asymptomatic except for signs of pelvic pressure This is the most common type of benign ovarian cyst; high malignancy rate of 20% to 30%. Therapy is surgical resection.
Carcinoma Asymptomatic; intermenstrual bleeding Ovarian cancer originates in epithelial tissue most often in women over 50 years of age. Tendency may be inherited; environmental contamination may play a role in development. Therapy is hysterectomy and salpingo-oophorectomy.

Endometrial polyp Intermenstrual bleeding Polyp is removed by dilatation and curettage.
Leiomyomas (fibroids) Asymptomatic or with increased menstrual flow Muscle and fibrous connective tissue form in response to estrogen stimulation. May increase in size during pregnancy; may cause interference with cervical dilatation and result in postpartal hemorrhage. Stress to the myometrium by uterine contractions may be the original cause of formation. Therapy is surgical resection (myomectomy) or hysterectomy if child-bearing is complete.
Endometrial carcinoma Vaginal bleeding between menstrual periods Diagnosis is by endometrial washing, not Pap test. Therapy is hysterectomy.
Uterine prolapse Vaginal pressure and low back pain The uterus has descended in the vagina due to overstretching of uterine supports and trauma to the levator ani muscle. Occurs most often in women who had insufficient prenatal care, birth of a large infant, a prolonged second stage of labor, bearing-down efforts or extraction of a baby before full dilatation, instrument birth, and poor healing of perineal tissue postpartally. Therapy is surgery to repair uterine supports or placement of a pessary, a plastic uterine support. Women with pessaries in place need to return for a pelvic examination every 3 months to have the pessary removed, cleaned, and replaced and the vagina inspected; otherwise, vaginal infection or erosion of the vaginal walls can result.


A woman's past experience with her reproductive system may have some influence on how well she accepts a pregnancy. Obtain information about her age of menarche (first menstrual period) and how well she was prepared for it as a normal part of life. Ask about her usual cycle, including the interval, duration, amount of menstrual flow, and any discomfort she feels. Ascertain her degree of discomfort, including when it occurs, how long it lasts, and what she does to relieve it. If she describes menstrual cramps as “horrible” and wonders “how I live through them some months,” anticipate the need for additional counseling to help her prepare for labor. Some women with severe dysmenorrhea look forward to pregnancy as it will mean 9 months without discomfort. Anticipate their need for counseling in the postpartum period about active ways to relieve their menstrual discomfort when their periods resume (see Chapter 47). Also ask if a woman does a monthly perineum self-examination (see Chapter 33 for this technique) to evaluate her interest in self-care. Breast self-examination is no longer thought to yield enough reliable information to be continued as a self-care routine (Kosters & Gotzsche, 2005).
Ask about past surgery on the reproductive tract. For example, if a woman has had tubal surgery, such as for an ectopic pregnancy, the statistical risk of another tubal pregnancy increases. If she has had uterine surgery, a cesarean birth may be necessary because her uterus may not be able to expand and contract as efficiently as usual because of the surgical scar. If she has undergone frequent dilatation and curettage of the uterus, her cervix may be weakened or unable to remain closed for 9 months. This could lead to premature birth unless she has a surgical procedure (cerclage) for this (see Chapter 15).

Ask also about what reproductive planning methods, if any, have been used. Occasionally, a woman may become pregnant with an intrauterine device (IUD) in place. If this occurs, it will be removed to prevent infection during pregnancy. Another woman, not realizing she is pregnant, may continue to take an oral contraceptive for some time into the pregnancy. Document whether such use occurred, because some evidence suggests that estrogen can harm fetal growth. Be certain to include a sexual history, including the number of sexual partners and use of safer sex practices, to establish the woman's risk for contracting a sexually transmitted infection.
As part of any woman's gynecologic history, assess for the possibility of stress incontinence (incontinence of urine on laughing, coughing, deep inspiration, jogging, or running). With these actions, the diaphragm descends, increasing abdominal pressure, which increases bladder tension and causes emptying. Stress incontinence occurs from lack of strength in the perineal muscles and bladder supports. Commonly, weakness occurs from difficult births, the birth of large infants, grand multiparity, and instrumented births. During pregnancy, stress incontinence can become intensified from the increasing abdominal pressure. Some women accept this incontinence as a normal consequence of childbearing and may not report it unless asked.
Women can relieve stress incontinence to some degree by strengthening the perineal muscles with the use of Kegel exercises (periodic tightening of the perineal muscles; see Chapter 11). Surgical correction to increase support to the bladder neck also could be performed following the pregnancy.
Obstetric History
Do not assume that the current pregnancy is a woman's first pregnancy simply because she is very young or says she has only recently been married. For each previous pregnancy, document the child's sex and the place and date of birth. Review the pregnancy briefly:
  • 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?
Ask about any previous miscarriages or abortions and whether she had any complications during or following them. Abortion is the medical term for any pregnancy terminated before the age of viability, commonly called a miscarriage. The age of viability is the earliest age at which fetuses could survive if they were born at that time, generally accepted as 24 weeks, or fetuses weighing more than 400 g. If the woman's blood type is Rh negative, ask if she received Rh immune globulin (RhIG [RhoGAM]) after miscarriages or abortions or previous births so you will know whether Rh sensitization could have occurred. Ask if she has ever had a blood transfusion to establish possible risk of hepatitis B or HIV exposure or Rh sensitization.
After a history of previous pregnancies is obtained, determine the woman's status with respect to the number of times she has been pregnant, including the present pregnancy (gravida), and the number of children above the age of viability she has previously borne (para). Table 10.2 explains these terms. For example, a woman who has had two previous pregnancies, has given birth to two term children, and is again pregnant is gravida 3, para 2. A woman who has had two miscarriages at 12 weeks (under the age of viability) and is again pregnant is a gravida 3, para 0.
A more comprehensive system for classifying pregnancy status (GTPAL or GTPALM) provides greater detail on a woman's pregnancy history. By this system, the gravida classification remains the same, but para is broken down into:
  • 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)

  • 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
Term Definition
Para The number of pregnancies that reached viability, regardless of whether the infants were born alive or not
Gravida A woman who is or has been pregnant
Primigravida A woman who is pregnant for the first time
Primipara A woman who has given birth to one child past age of viability
Multigravida A woman who has been pregnant previously
Multipara A woman who has carried two or more pregnancies to viability
Nulligravida A woman who has never been and is not currently pregnant
Using this system, the woman in the first example above would be gravida 3, para 2002 (GTPAL) or 320020 (GTPALM). A multigestation pregnancy is considered as one para. For example, a woman who had term twins, then one preterm infant, and is now pregnant again would be a gravida 3, para 21031 (GTPALM).
A pregnant woman who had the following past history—a boy born at 39 weeks' gestation, now alive and well; a girl born at 40 weeks' gestation, now alive and well; a girl born at 33 weeks' gestation, now alive and well—would have her pregnancy information summarized as follows: gravida 4; para 21030 (GTPALM).
Review of Systems
A review of systems completes the subjective information. Use a systematic approach, such as head to toe, and explain what you'll be doing. For example, “I'm going to start at the top of your head and go through to your toes, asking about body parts or systems and any diseases that you may have had.” A review of systems helps women recall diseases they forgot to mention earlier, such as a urinary tract infection, a disease that can influence the outcome of pregnancy and so would be important to your history taking.
The following body systems and questions about conditions constitute the minimum information to be addressed in a review of systems for a first prenatal visit:
  • 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?
End an interview by asking if there is something you have not covered that the woman wants to discuss. This gives her one more chance to ask any questions she has about this new life experience.
Support Person's Role
More and more partners accompany women for prenatal care today. Young children may also accompany their mothers on these visits. Some women bring a female friend as their best support person. If family members are present, should they be included in an initial interview? As a whole, interviewing is most effective if it is a one-to-one interaction. A woman may be unwilling to mention certain concerns when her family is present for fear of worrying them. A husband may not be the father of her child, and she may be unable to voice her concern over this fact or alert you to the possibility she is worried about blood incompatibility because another man is the father.
If childbearing is to be a family affair, however, it is important to determine the partner's degree of acceptance of the pregnancy and of assuming a new parenting role. Including siblings in a prenatal visit provides them with an opportunity to involve them with the pregnancy planning and coming baby. Interviewing the woman alone and then inviting the support person and family to join her while you talk about pregnancy symptoms with them as a family is an effective solution (Fig. 10.1). Providing some private interview time with a partner allows the partner to express any concerns or worries. The main areas you should investigate with the partner include his current health, his feelings and concerns about the pregnancy, and his knowledge of pregnancy and childbirth. If the woman wishes, the partner can accompany her during the physical examination. After the confirmation of pregnancy, the partner should be included when health care information is given (Box 10.8).
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.)

Physical Examination
After a health history is obtained, women have a physical examination. If a woman voids for a clean-catch urine before the exam, this can reduce bladder size and make the pelvic examination more comfortable, allow easier identification of pelvic organs, as well as providing a urine specimen for laboratory testing. The urine specimen is sent to the laboratory for evaluation of bacteria, protein, glucose, and ketones, or these can be immediately tested by dipstick analysis. Box 10.9 provides instructions on how to obtain a clean-catch urine sample.
A physical examination at a first prenatal visit typically includes inspection of body systems, with emphasis on the changes that occur with pregnancy or that could signal a developing problem. General techniques of physical examination are discussed in Chapter 33.
Baseline Height/Weight and Vital Sign Measurement
A woman's weight and height are obtained at a first prenatal visit to establish a baseline for future comparison. Record this assessment with her prepregnancy weight, if available, to determine how much weight she has already gained or lost (Fig. 10.2). When weighing, be certain to convey an air of “accuracy is what counts” instead of censoring weight gain so the woman feels comfortable gaining 30 to 35 lb during pregnancy (many adolescents need to gain 40 lb to ensure a healthy fetus).
Vital signs, including blood pressure, respiratory rate, and pulse rate, are measured for baseline information. A sudden increase in blood pressure, like a sudden weight gain, is a danger sign of hypertension of pregnancy. A sudden increase in pulse or respirations may suggest bleeding. If close monitoring will be necessary during pregnancy, a support person or the woman herself can be taught the technique of blood pressure recording.
Assessment of Systems
General Appearance and Mental Status
Physical examination always begins with an inspection of general appearance to form an overall impression of the woman's health and well-being. General appearance is important because it reveals how people feel about themselves by the manner in which they dress, the way they speak, and the body posture they assume. Not all women are happy about being pregnant. Closely inspect for signs such as careless hygiene, unwashed hair, inappropriate or soiled clothing, and sad facial expression that may suggest fatigue or depression (Marcus et al., 2003).
If the woman has any bandages and other dressings in place, be sure to remove and replace them because they could hide an important finding such as a malignant melanoma or skin cancer, which are increasing problems in young adults (Freak, 2004).
A second increasing problem, or perhaps one receiving increased recognition, is intimate partner abuse, a condition that not only is dangerous to the woman but also may lead to early pregnancy loss (Janssen et al, 2003). Ask when and how any skin abnormality, such as an ecchymotic area, occurred. Most marks from battering occur on the face, the ulnar surfaces of the forearms (from a woman raising her arms to defend herself), the abdomen or buttocks (from being kicked), or the upper arms (from being grabbed and held forcefully). Noting the color of ecchymotic spots helps to date when they occurred. Such marks typically progress through purple to yellow changes.
Head and Scalp
Examine the woman's head for symmetry, normal contour, and tenderness and the hair for presence, distribution, thickness, excessive dryness or oiliness, cleanliness, or the use of hair dye (hair dye may be carcinogenic over an extended period of time). Look for chloasma (extra pigment on the face that occurs from melanocyte-stimulating hormone), which may accompany pregnancy. Hair growth speeds up during pregnancy as a result of the overall increased metabolic rate, and women may comment they have noticed this. Dryness


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.)
Edema of the eyelids combined with a swollen optic disk (identified on ophthalmoscopic examination) suggests edema from pregnancy-induced hypertension, a potentially dangerous condition in pregnancy. On interview, women with pregnancy-induced hypertension also usually report spots before their eyes or diplopia (double vision). Teach pregnant women to recognize symptoms of poor vision as a potential danger sign of pregnancy that should be reported as soon as possible. If they do close desk work, caution them to take a break every hour so they do not confuse sensations of eyestrain with actual danger signs.
The increased level of estrogen associated with pregnancy may cause nasal congestion or the appearance of swollen nasal membranes. Even topical medicines such as nose drops or nasal sprays used to reduce this are absorbed to some degree. Advise a woman to avoid these during pregnancy without her physician's or nurse-midwife's knowledge and consent.

The nasal stuffiness that accompanies pregnancy may lead to blocked eustachian tubes and therefore a feeling of “fullness” in the ears or dampening of sound during early pregnancy. Usually this disappears as the body adjusts to the new estrogen level. Normal hearing level and normal tympanic landmarks should be present.
Sinuses should feel nontender. Establishing that tenderness over sinuses does not exist helps to evaluate that a client's reports of headache during pregnancy (a danger sign until ruled otherwise) is probably not sinus-related.
Mouth, Teeth, and Throat
Gingival (gum) hypertrophy may result from estrogen stimulation during pregnancy. The gums may be slightly swollen and tender to the touch, but not reddened. The pregnant woman is prone to vitamin deficiency because of the rapid growth of the fetus. Assess carefully for cracked corners of the mouth, which would reveal vitamin A deficiency. Assess carefully for pinpoint lesions with an erythematous base on the lips; these suggest a herpes infection (a herpes lesion on the gumline is more often a shallow ulcer). Because newborns are susceptible to herpes infection, lesions present at birth may necessitate limiting the woman's contact with her newborn.
Teach all women not to neglect good dental hygiene or yearly dental visits while pregnant. They should maintain thorough toothbrushing (some stop thorough brushing because they notice slightly blood-tinged saliva due to gingival hypertrophy).
If many dental caries are obvious, the woman should be referred to a dentist or dental clinic. Carious teeth are a source of infection and should be treated before abscesses develop and cause more serious problems. Contrary to what many women believe, dental x-rays can be taken during pregnancy as long as the woman reminds her dentist she is pregnant and is given a lead apron to shield her abdomen. Urge her to obtain permission from her primary care provider before consenting to extensive dental work requiring anesthesia.
Slight thyroid hypertrophy may occur with pregnancy because the overall metabolic rate is increased. All women should eat seafood once weekly to supply enough iodine for the accompanying increased thyroxine production (eating tuna more often than that is contraindicated, however, because of potentially high mercury content) (Stephenson, 2004). Encourage a woman who uses iodized salt to continue using this during pregnancy. Without this precaution, some women will view iodine as an unnecessary additive and discontinue using it during pregnancy.
Lymph Nodes
No palpable lymph nodes should be present; however, because pregnant women may develop an increased number of upper respiratory infections due to reduced immunologic resistance, one or two pea-sized cervical lymph nodes may be palpable. If a woman has a tooth abscess from bacterial growth under hypertrophied gingival tissue (periodontal disease), submaxillary lymph nodes may be palpable.
Breast changes may be one of the first things women notice in pregnancy:
  • 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.
Benign breast lesions that might be discovered on physical examination are discussed in Chapter 47.
Heart rate typically ranges from 70 to 80 beats per minute, and no accessory sounds or murmurs should be present. Occasionally, a woman may develop an innocent (functional) heart murmur during pregnancy because of the increased vascular volume. If this occurs, she needs further evaluation to ensure that it is only a physiologic change of pregnancy and not a previously undetected heart condition. Many women notice occasional palpitations (heart skipping a beat) during pregnancy, especially when lying supine. Teach pregnant women always to rest or sleep on their side (left side is best) to help avoid this problem.
Assess respiratory rate and rhythm. Although lung tissue assumes a more horizontal position during pregnancy, vital capacity is not reduced. Late in pregnancy, diaphragmatic excursion (diaphragm movement) is lessened because the diaphragm cannot descend as fully as usual because of the distended uterus.
The lumbar curve in many pregnant women is accentuated on standing so that they can maintain body posture in the face of increasing abdominal size. This response may cause considerable back pain during pregnancy. Assess the spine for any abnormal curve that would suggest scoliosis. Young women with scoliosis may need a referral to their orthopedist during pregnancy to be certain that their condition is not worsening.
Assess the rectum closely for hemorrhoidal tissue, which commonly occurs from uterine pressure on pelvic veins preventing venous return. Hemorrhoids can be very uncomfortable for women and worrisome if they are not assured that hemorrhoids are a normal discomfort of pregnancy.
Extremities and Skin
Many women develop palmar erythema and itching early in pregnancy from a high estrogen level and perhaps subclinical jaundice (jaundice that is not yet apparent by a color change) from reabsorbed bilirubin due to slowed intestinal peristalsis. Assess the lower extremities carefully for varicosities, filling time of the toenails (which should be under 5 seconds), and the presence of edema caused by impaired venous return from the lower extremities. Any edema more than ankle swelling may be a danger sign of pregnancy.
Assess the gait of pregnant women to see that they are keeping their pelvis tucked under the weight of their

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.
Measurement of Fundal Height and Fetal Heart Sounds
At about 12 to 14 weeks of pregnancy, the uterus is palpable over the symphysis pubis as a firm globular sphere. It reaches the umbilicus at 20 to 22 weeks and the xiphoid process at 36 weeks, and then often returns to about 4 cm below the xiphoid due to “lightening” at 40 weeks. If the woman is past 12 weeks of a pregnancy, palpate the fundus location, measure the fundal height (from the notch above the symphysis pubis to the superior aspect of the uterine fundus), and plot the height on a graph such as the one shown in Figure 10.3. Plotting uterine growth at each visit can help detect any unusual variation in fetal growth. If an abnormality is detected, further investigation with ultrasound can be done to determine the cause of the unusual increase or decrease in growth.
Auscultate for fetal heart sounds (120 to 160 beats per minute). These can be heard at 10 to 12 weeks if a Doppler technique is used but not until 18 to 20 weeks if a regular stethoscope is used. Palpate for fetal outline and position after the 28th week.
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.
Pelvic Examination
A pelvic examination reveals information on the health of both internal and external reproductive organs. It requires the following equipment: a speculum (a metal or plastic instrument with movable flat blades; Fig. 10.4), a spatula for cervical scraping, a clean examining glove, lubricant, a glass slide or liquid collection device for the Pap smear, a culture tube, two or three sterile cotton-tipped applicators or cytobrushes for obtaining cervical cultures, a good examining light, and a stool at correct sitting height (Keye & Damewood, 2003).
Be aware that pelvic examinations have the reputation of being painful and, of course, cause a loss of modesty. If this is a first pregnancy, it may be the first time a woman has ever had this type of exam. Having heard stories about how painful these examinations are may cause her to tense just thinking about it. When the pelvic muscles are tight and tense, not only does the examination become painful, but also the examiner has difficulty assessing the status of the pelvic organs.
Allow the woman the opportunity to talk with the person performing the examination while sitting up, before being placed in a lithotomy position (Fig. 10.5): it may enhance her sense of self-esteem and control to meet her examiner first while in this position. Many women want their support person to remain with them at the head of the table during the examination. In addition, it is customary, especially on an initial visit, for a nurse or a nursing assistant to be in the room with a woman for the pelvic examination to offer additional support. This is true whether the examiner is male or female.
When serving as a support person, remain at the head of the table; do not stand at the foot of the table. Being at the head of the table enables you to hold the woman's hand or put a hand on her shoulder if she needs the support of physical contact. Explanations of what is happening or what the examiner is doing are helpful. Conversation with the examiner over her head is not. Suggesting that a woman breathe in and out (not hold her breath as she is likely to do) is another technique to help her relax (holding her breath pushes the diaphragm down and makes the pelvic organs tense and unyielding).
Before a pelvic examination, a woman should void to reduce her bladder size and then lie in a lithotomy position

(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.
Properly drape her with a draw sheet over her abdomen that extends over her legs. Be sure pregnant women remain in a lithotomy position for as short a time as possible to help prevent thromboembolism and supine hypotension syndrome.
If desired, a woman may watch the pelvic examination with an overhead mirror or a mirror held by herself or the examiner. Seeing vaginal cervical pathology can help her to understand any kind of problem present and the interventions necessary to improve it. If not already doing so, sexually active women should be taught how to do a monthly perineal examination (holding a mirror) so they can detect perineal lesions such as herpes simplex 2 viral infections.
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.
External Genitalia
A pelvic examination begins with inspection of the external genitalia. Any signs of inflammation, irritation, or infection, such as redness, ulcerations, or vaginal discharge, are noted.
A herpes simplex 2 virus infection appears as clustered, pinpoint vesicles on an erythematous (reddened) base on the vulva. These feel painful when touched or irritated. It is important to detect these during pregnancy as the presence of herpes lesions on the vulva or vagina at the time of birth may necessitate cesarean birth to prevent exposing the fetus to the virus during passage through the birth canal. There may be an association between cervical cancer and herpes simplex 2 infections. Note in the record the presence of a herpes infection for future follow-up with cytologic (Pap) smears for cervical cancer.
The Skene glands that empty into the urethra are checked for infection. To do this, a sterile gloved finger is inserted into the vagina and pressed against the anterior vaginal wall to see if any pus can be extruded from the openings to the glands at the urethral opening. The woman is also evaluated for possible infection of the Bartholin glands that enter into the distal vagina. The sites of the Bartholin glands (5 and 7 o'clock positions) are palpated between the vaginal finger and the thumb of the same hand. If a discharge is produced from any of these gland ducts (Skene or Bartholin), a culture is obtained. Infection here could be caused by something as simple as streptococci; often it is gonorrhea.
Problems with vascular muscle wall support, such as a rectocele (a forward pouching of the rectum into the

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.
Internal Genitalia
To view the cervix, the vagina must be opened with a speculum. No lubricant other than warm water should be used over the speculum blades because even a water-soluble lubricant might interfere with the interpretation of the Pap smear that will be taken. Warm water rather than cold water should be used so the woman does not contract her vaginal muscles when she feels the cold instrument.
A speculum is introduced with the blades in a closed position and directed toward the posterior rather than the anterior vaginal wall because the posterior wall is less sensitive (see Fig. 10.4A). A speculum enters most readily if it is inserted at an oblique angle (the crease of the blades directed to 4 or 8 o'clock), then rotated to a horizontal position when fully inserted (the crease of the blades pointing to a 3 or 9 o'clock position) (see Fig. 10.4B). When fully inserted and rotated to a horizontal position, the blades are opened so the cervix is visible and are secured in the open position by tightening the thumb screw at the side (see Fig. 10.4C).
With the speculum in place, the cervix can be inspected for its position. Normally it is centered on the vagina; a retroverted uterus has a cervix positioned anteriorly, and an anteverted uterus has its cervix positioned posteriorly. The cervix color (a nonpregnant cervix is light pink; in pregnancy it changes to almost purple) and any lesions, ulcerations, discharge, or otherwise abnormal appearance are documented.
In a nulligravida (a woman who is not or never has been pregnant), the cervical os is round and small. In a woman who has had a previous pregnancy with a vaginal birth, the cervical os has much more of a slitlike appearance (Fig. 10.6A). If the woman had a cervical tear during a previous birth, the cervical os may appear as a transverse crease the width of the cervix or a typical starlike (stellate) formation. If a cervical infection is present, a mucus discharge may be present. With infection, the epithelium of the cervical canal often enlarges and spreads onto the area surrounding the os, giving the cervix a reddened appearance (erosion; see Fig. 10.6C). This area bleeds readily if it is touched.
Trichomoniasis, a protozoal infection, generally gives signs of redness; a profuse, whitish, bubbly discharge; and petechial spots on the vaginal walls. Candidal (Monilia) infection typically presents with thick, white vaginal patches that may bleed if scraped away. A gonorrhea infection typically presents with a thick, greenish-yellow discharge and extreme inflammation. Chlamydia infection, in contrast, shows few symptoms except slight cervical redness.
Carcinoma of the cervix appears as an irregular, granular growth at the os. Cervical polyps (red, soft, pedunculated protrusions) also are occasionally seen at the os.
Pap Smear
A Pap smear is taken for early detection of cervical cancer and diagnosis of precancerous and cancerous conditions of the vulva and vagina; it also reveals inflammatory and infectious diseases. Although only an endocervical smear (one from inside the cervix) may be taken to be plated for a Pap test in some centers, in others three separate specimens—one from the endocervix, one from the cervical os, and one from the posterior vaginal fornix—are obtained (Fig. 10.7). In addition, a cervicogram (a photograph of the cervix) may be taken. Cervicograms serve as complements to Pap smears as a weapon for detecting cervical cancer and documenting that lesions from infections are healing.
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 obtain an endocervical specimen for a Pap smear, a sterile cotton applicator, wet with saline, is inserted through the speculum into the os of the cervix and gently rotated, first clockwise, then counterclockwise (see Fig. 10.7A). It is then removed without touching the sides of the vagina. The specimen is then gently painted on a glass slide. The slide is sprayed with a fixative to preserve the cells. Use of cytobrushes for pregnant women is not recommended, because they can cause cervical bleeding due to increased cervical softening (Fischbach, 2004).
To take a cervical os specimen, the uneven end of a spatula is inserted through the speculum and pressed on the os of the cervix and rotated to scrape cells in a circle around the os (see Fig. 10.7B). After removal, the spatula is then smeared onto a slide and the slide is sprayed with fixative.
For the specimen from the posterior vaginal fornix, a cotton-tipped applicator or the opposite end of the spatula blade is placed at the posterior fornix just below the cervix (the vaginal pool; see Fig. 10.7C). The applicator or spatula is rolled gently to pick up secretions collected there. After careful removal, the specimen is placed on a third slide and sprayed with fixative. Many Pap smears are read by computer today, an advance that has made the collection of specimens slightly different. If a ThinPrep Pap smear is being taken, a small broomlike collection device is inserted into the endocervical canal deep enough

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.
The classification of Pap smears is constantly being revised as the meaning of abnormal cells is further defined (Davey, 2003). The Bethesda classification of Pap smears is shown in Table 10.3. Be certain when discussing these reports with women that they do not overinterpret the results. The first category means only normal cells were found. The second category means cells are inflamed because infection is present (the woman needs to be treated and reexamined in about 3 months). At the next level (LSIL), cells are moderately suspicious for malignancy. The HSIL category identifies that precancerous cells are present. This level requires a colposcopy examination for further evaluation. Only the last category is indicative that squamous cell carcinoma is present. Therapy at this level will include colposcopy, biopsy, and removal of the affected cells, usually by conization.
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.
Many women ask how often repeat Pap smears are necessary because the recommendations have changed. The American Cancer Society recommends women begin to have Pap smears when they turn 18 or become sexually active (whichever is first). They may be necessary as infrequently as every 3 years in women who have had two consecutive negative tests a year apart. Women who should have them more frequently are those who have multiple sexual partners, who have a history of human papillomavirus (HPV) infection, who smoke cigarettes, or who were active sexually before age 21. Screening as infrequently as every 3 years could miss pathology in these women.
Women who engage in anal intercourse may have an anal swab taken as well as vaginal swabs to detect anal squamous neoplasms. The technique for obtaining anal Pap smears is the same as that for vaginal specimens (a cytobrush is used). Caution the patient that she may have slight rectal bleeding following the procedure.
Vaginal Inspection
Before the speculum is removed, a culture for gonorrhea, chlamydia, or group B streptococcus may be taken. After gently swabbing the cervix using cotton-tipped applicators, the specimens obtained are then plated onto a medium to allow for their growth. All these organisms can cause disease in the newborn, so it is best if they can be eradicated during pregnancy.
A speculum must be unlocked and partially closed before removal; otherwise, pain from excessive stretching could occur. If the speculum is kept partially open as it is removed, it should not cause any pain, and the sides of the vagina can be inspected as it is withdrawn. In a nonpregnant woman, vaginal walls are light pink; pregnancy

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)
Classification Findings

Negative for intraepithelial lesion or malignancy

Cell changes caused by organisms:

  • Trichomonas vaginalis
  • Fungal organisms morphologically consistent with Candida species
  • Shift in flora suggestive of bacterial vaginosis (coccobacillus)
  • Bacteria morphologically consistent with Actinomyces species
  • Cellular changes consistent with herpes simplex virus Other nonneoplastic findings

Reactive changes associated with:

  • Inflammation (includes repair)
  • Radiation
  • IUD use

Glandular cells status after hysterectomy
Endometrial cells (in women >40 years of age)

2 Atypical squamous cells of undetermined significance (ASCUS)

Low-grade squamous intraepithelial lesion (LSIL)

Changes include those caused by:

  • Human papillomavirus (HPV)
  • Mild dysplasia
  • Cervical intraepithelial neoplasm (CIN) grade 1 (low-grade precursor)

High-grade squamous intraepithelial lesion (HSIL)

Changes include those caused by:

  • Moderate to severe dysplasia
  • CIN grades 2 and 3 (high-grade precursors)—formerly carcinoma in situ (CIS)

Has features suspicious for invasion

5 Squamous cell carcinoma
Examination of Pelvic Organs
Following the speculum examination, a bimanual (two-handed) examination is performed to assess the position, contour, consistency, and tenderness of pelvic organs (Fig. 10.9). The index and middle fingers of one gloved hand are lubricated and inserted into the vagina so the walls of the vagina can be palpated for abnormalities. The other hand is then placed on the woman's abdomen and pressed downward toward the hand still in the vagina until the uterus can be felt between them. If a uterus is extremely retroverted, it may not be palpable abdominally. Next, the right and left ovaries are identified by the same method. Ovaries are normally slightly tender, so the pressure caused by palpation may cause the woman some discomfort.
Abnormalities that can be noted by bimanual examination include ovarian cysts, enlarged fallopian tubes (perhaps from pelvic inflammatory disease), and an enlarged uterus (see Table 10.1). An early sign of pregnancy (Hegar's sign) is elicited on bimanual examination as well (see Fig. 9.4).
Rectovaginal Examination
After a bimanual pelvic examination, the hand is withdrawn from the vagina. The index finger is reinserted into the vagina and the middle finger into the rectum. By palpating the tissue between the examining fingers in this way, it is possible to assess the strength and irregularity of the posterior vaginal wall. This maneuver may be slightly uncomfortable for the woman because of the rectal pressure involved. Some examiners use a clean pair of gloves before they perform a vaginal-rectal examination so they will not spread an infection from the vagina to the rectum. After the rectal examination, if it is necessary to reexamine the vagina for any reason, the glove must be changed to avoid contaminating the vagina with fecal material.
After completing the examination, any excess lubricant is wiped away from the vaginal and rectal openings. It is important to wipe front to back to prevent bringing rectal contamination forward to the vaginal introitus.

FIGURE 10.9 A bimanual examination to determine uterine size.
Estimating Pelvic Size
It is impossible to predict from the outward appearance of a woman whether her pelvic ring will be adequate for a fetus to pass through its center. Some women look as if they have a wide pelvis but, in reality, have only wide iliac crests and a normal or even smaller-than-normal internal ring. Other women appear as if their pelvis will be small because the iliac crests are nonflaring, but the internal pelvis, the part that must be sufficiently large for childbirth, is of average size, allowing them to give birth vaginally without difficulty. Differences in pelvic contour and development occur mainly because of hereditary factors, but disease (e.g., rickets, now rarely seen in the United States, which may cause contraction of the pelvis) or injury (inadequate repair following an accident) also may play a role.
If on this initial visit the primary care provider establishes that the woman is pregnant, and if she has never given birth vaginally before, pelvic measurements may be taken. Some care providers prefer to take these measurements later in pregnancy, when the woman's pelvic muscles are more relaxed, making measurement easier. If a routine sonogram is scheduled, estimations may be made by a combination of pelvic pelvimetry and fetal sonography. Estimation of pelvic adequacy must be done at least by the 24th week of pregnancy, because by this time there is danger that the fetal head will reach a size that will interfere with safe passage and birth if the pelvic measurements are small.
Once a woman has given birth vaginally, her pelvis has been proven adequate. Thus, it is not necessary to take her pelvic measurements again unless she has had an intervening history of trauma to the pelvis.
The types of pelves found in women can be categorized into four groups (Fig. 10.10): android, anthropoid, gynecoid, and platypelloid.
Internal pelvic measurements give the actual diameters of the inlet and outlet through which the fetus must pass. The following measurements are made most commonly:
  • 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 the

    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.
Laboratory Assessment
A number of laboratory studies are included in assessment measures at a first prenatal visit to confirm general health and rule out sexually transmitted infection that could injure the growing fetus. Normal levels for these studies are shown in Appendix F.
Blood Studies
The following blood studies are usually done at a first prenatal visit:
  • 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 may

    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-antagonistic

    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.
A urinalysis is performed to test for proteinuria, glycosuria, and pyuria. All three of these can be done by means of test strips and microscopic examination of the urine.
Tuberculosis Screening
The incidence of tuberculosis is on the rise, related to the HIV epidemic. More people with lowered immune system resistance (i.e., those with HIV infection) are contracting tuberculosis and then spreading it to others. In light of this, the physician or nurse-midwife may order a purified protein derivative (PPD) tuberculin test to screen for tuberculosis. Any woman who has a positive reaction would then require a chest x-ray for further diagnosis.
If a woman has a history of tuberculosis or has received a BCG vaccine for tuberculosis, a tuberculin skin test should not be given because the reaction would be extreme. Although BCG vaccine is not administered in the United States, immigrants from other countries may have received this. To assess a woman's current disease status, a chest x-ray may be ordered. A woman is often reluctant to have this done because she knows radiation is harmful to a growing fetus. Assure her that she will be given a lead apron to cover her abdomen to protect the fetus, exposing only her chest to radiation.
Screening for tuberculosis early in pregnancy is important because it is a chronic and debilitating disease that increases the risk of miscarriage. Further, the change in the shape of the lung tissue as the growing uterus presses on the lung may reactivate old lesions.
If the date of the last menstrual period is unknown, a woman will be scheduled for a sonogram to confirm the pregnancy length and document healthy fetal growth.
Risk Assessment
Table 10.4 summarizes necessary data assessment for a first prenatal visit. After this assessment, findings are analyzed to determine whether this pregnancy is apt to continue with a good outcome or there is some risk that it will end before term or with an unfavorable fetal or maternal outcome (a high-risk pregnancy).
Many factors enter into the categorization of high risk. Most health care agencies use some tool to determine high risk, but no tool is perfect because the concept of high risk is a very individualized one. Table 10.5 lists factors


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
Health History
Demographic data Name, address, age, telephone number, health insurance
Chief concern Was pregnancy planned? When was last menstrual period? Any exposure to infectious diseases or ingestion of drugs since she thinks she has been pregnant?
Family and social profile What is family composition? Who is her chief support person? What is her occupation? Source of income? Level of exercise? Hobbies? Recreational drug use? Living conditions? Nutrition? Sleep pattern?
Past medical history Any abdominal surgery, kidney, heart, hypertension, sexually transmitted infections, diabetes, allergies?
Gynecologic history When was menarche? What is length and duration of menstrual cycle?
Obstetric history Any previous pregnancies? When? Type and outcome of birth? Any history of previous miscarriages?
Review of systems Brief review of all body systems
Physical Examination
Baseline data Height, weight, vital signs, fundal height measurements (after 12 weeks), fetal heart sounds
System assessment Full physical examination to confirm general health
Pelvic examination General assessment, Pap smear, cultures for chlamydia, gonorrhea, group B streptococcus, pelvic measurements
Laboratory Assessment
Blood assessment Complete blood count, serologic test for syphilis, blood type and Rh, alpha-fetoprotein, antibody titer against Rh, hepatitis B, rubella, and possibly varicella and HIV.
Urinalysis Clean catch for glucose, protein, ketones, and culture
Tuberculosis PPD test
Ultrasound To date pregnancy or confirm fetal health (if date of last menstrual period is unknown)
TABLE 10.5 Assessments That Might Categorize a Pregnancy as At Risk
Obstetric History History of infertility or grand multiparity
Premature cervical dilatation
Uterine or cervical anomaly
Previous preterm labor or preterm birth or cesarean birth
Previous macrosomic infant
Two or more spontaneous or elective abortions
Previous hydatidiform mole/choriocarcinoma
Previous ectopic pregnancy or stillborn/neonatal death
Previous multiple gestation
Previous prolonged labor
Previous low-birthweight infant
Previous midforceps delivery
Last pregnancy less than 1 year previous
Previous infant with neurologic deficit, birth injury, or congenital anomaly
Medical History Cardiac or pulmonary disease, chronic hypertension
Metabolic disease
Renal disease, recent urinary tract infection, or bacteriuria
Gastrointestinal disorders
Seizure disorders
Family history of severe inherited disorders
Surgery during pregnancy
Emotional disorders or cognitive challenge
Previous surgeries, particularly involving reproductive organs
Endocrine disorders
Sexually transmitted infections
Reproductive tract anomalies, history of abnormal Pap smear, malignancy
Current Obstetric Status Inadequate prenatal care
Intrauterine growth-restricted fetus
Large-for-gestational-age fetus
Pregnancy-induced hypertension or preeclampsia
Abnormal fetal surveillance tests
Placenta previa
Abnormal presentation
Maternal anemia
Weight gain under 10 lb or weight loss over 5 lb
Fetal or placental malformation
Rh sensitization
Preterm labor
Multiple gestation
Premature rupture of membranes
Abruptio placentae
Postdate pregnancy
Fibroid tumors
Fetal version
Cervical cerclage
Sexually transmitted infection
Other maternal infection
Poor immunization status
Psychosocial Factors Inadequate finances
Lack of support person
Poor nutrition
More than two children at home; no help
Lack of acceptance of pregnancy
Attempt or ideation of suicide
Inadequate or poor housing
Father of baby uninvolved
Minority status
Dangerous occupation
Dysfunctional grieving
Psychiatric history
Demographic Factors Maternal age under 16 or over 35
Education under 11 years
Lifestyle Cigarette smoking greater than 10 cigarettes a day
Substance abuse
Long amounts of time spent commuting
Nonuse of seatbelts
Alcohol intake
Heavy lifting or long periods of standing
Unusual stress
No in-home smoke detectors
Risk assessment should be updated at each pregnancy visit, as the failure to identify risk potential in pregnancy leads to increased perinatal mortality. See Chapters 14, 15, 16 and 17 for a more detailed discussion of high-risk pregnancy and its management.
Important aspects of ongoing prenatal care are discussed in Chapter 11. Box 10.10 lists components of assessments and care done during continuing prenatal visits.
Key Points
  • 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 comfortable

    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.
Critical Thinking Exercises
  • 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?
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Buehler, B. A. (2003). Interactions of herbal products with conventional medicines and potential impact on pregnancy. Birth Defects Research: Developmental and Reproductive Toxicology, 68 (6), 494–495.
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Suggested Reading
Browne-Krimsley, V. (2004). Lessons learned: providing culturally competent care in a nurse-managed center. ABNF Journal, 15 (4), 71–73.
Dillard, R. G. (2004). Improving pre-pregnancy health is key to reducing infant mortality. North Carolina Medical Journal, 65 (3), 147–148.
Gramling, L., Hickman, K., & Bennett, S. (2004). What makes a good family-centered partnership between women and their practitioners? Birth, 31 (1), 43–48.

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Jesse, D. E., & Graham, M. (2005). Are you often sad and depressed? Brief measures to identify women at risk for depression in pregnancy. MCN: The American Journal of Maternal/Child Nursing, 30 (1), 40–45.
Jesse, D. E., Seaver, W., & Wallace, D. C. (2003). Maternal psychosocial risks predict preterm birth in a group of women from Appalachia. Midwifery, 19 (3), 191–202.
Lazarus, E. (2003). What's new in first trimester ultrasound. Radiologic Clinics of North America, 41 (4), 663–679.
Lewallen, L. P. (2004). Healthy behaviors and sources of health information among low-income pregnant women. Public Health Nursing, 21 (3), 200–206.
Sackett, K., Pope, R. K., & Erdley, W. S. (2004). Demonstrating a positive return on investment for a prenatal program at a managed care organization: an economic analysis. Journal of Perinatal and Neonatal Nursing, 18 (2), 117–127.
Schrag, S. J., et al. (2003). Prenatal screening for infectious diseases and opportunities for prevention. Obstetrics and Gynecology, 102 (4), 753–760.
Singer, L. T., et al. (2004). Cognitive outcomes of pre-school children with prenatal cocaine exposure. JAMA, 292 (2), 171.
Vidaeff, A. C., Franzini, L., & Low, M. D. (2003). The unrealized potential of prenatal care: a population health approach. Journal of Reproductive Medicine, 48 (11), 837–842.

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