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Maternal History. By Prof. Unn Hidle Updated Spring 2010. VIDEO SUGGESTIONS. Prior to this lab, it is strongly recommended that you watch the following audio-visual: Physical Assessment: The Breast Exam (Video) Physical Assessment: The Gynecological Exam (Video)
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Maternal History By Prof. Unn Hidle Updated Spring 2010
VIDEO SUGGESTIONS • Prior to this lab, it is strongly recommended that you watch the following audio-visual: • Physical Assessment: The Breast Exam (Video) • Physical Assessment: The Gynecological Exam (Video) • In the Womb (Video – National Geographic) • Nine Month Miracle, A.D.A.M. Essentials Software (1999). [CD-ROM]
Gravida and Para • Gravida = Number of pregnancies • Nulligravida = Never pregnant • Primigravida = First pregnancy • Multigravida = Has been pregnant before • Para = Number of deliveries that have gone to viability (20-24 weeks & 500 grams): • Number of deliveries regardless of how many infants in one delivery, or if the infant is born dead or alive. • Thus twins, triplets, etc. count as one pregnancy and one birth (Gravida 1; Para 1)
Gravida and para: Example • Jane is pregnant for the 4th time. She has 4 living children (all full term), two of them are twins • G4P3
TPAL • More comprehensive data in which gravida means the same • T=number of term pregnancies/births (37weeks) • P=number of preterm pregnancies/births (between 20 weeks and 37 weeks) • A=number of pregnancies aborted - miscarriages/spontaneious or induced - (remember statistically <20 weeks, although abortions can occur later than that) • L=number of currently living children
Example of using TPAL • Liz is pregnant for the 4th time. She has one living child who was born at 35 weeks gestation • One pregnancy ended at 10 weeks’ gestation • She gave birth to another infant stillborn at term
Answer • Gravida 4 • Para 1111 • The way it is written: G4 p1111
Figure this one out…….. • A woman is now pregnant at 20 weeks gestation. She has the following previous medical history: • Abortion @ 8 weeks gestation • Abortion @ 21 weeks gestation • 1 stillbirth @ 22 weeks gestation • 1 delivery @ 36 weeks gestation. Now one living child • 1 delivery @ 38 weeks gestation. Now one living child • Twins @ 42 weeks gestation. Now living twins • What would the GP and GTPAL be for this woman?
Importance of pre-natal care Detect high risk pregnancy as well as proper teaching to expectant mothers Risk factors are any findings that suggest the pregnancy may have a negative outcome for either the woman or unborn child Screening tests for risk factors are an essential part of the prenatal assessment
By identifying high risk pregnancies early, appropriate interventions can be started promptly • Prenatal assessment includes a comprehensive history and a physical exam
Initial prenatal assessment • The prenatal assessment focuses on the woman holistically by considering physical, cultural and psychosocial factors that influence her health • The establishment of the nurse-client relationship will help the woman evaluate the health team and also provide the nurse with a basis for developing an atmosphere that is supportive and educational • What is included in the prenatal assessment?
The initial prenatal visit is comprehensive: • pelvic exam and bimanual exam • specific blood serum tests • urine test • pap smear • The following visits do not include a pelvic/vaginal exam (unless there are complications), but always include • vital signs • urine test • serum tests as indicated).
Vaginal Exam IMPORTANT NURSING INTERVENTIONS: • Before perfroming a pelvic (vaginal) exam ALWAYS ask the patient to empty bladder • During the pelvic exam, tell the patient to take a deep breath and then bear down during the exam
Physical changes occurs from early pregnancy: • Godell’s sign = softening of the cervix • Hegar sign = excessive soft wall of the isthmus of the uterus (between the cervix and the uterus) • Chadwick’s sign = discoloration (may be bluish, purple or deep red) of the mucosal membranes of the cervix, vagina and vulva Culture and sensitivity test is also done to rule out bacterial infections
Pap smear= Papanicolaou test: • Always do the Pap smear firstbefore manipulation with the pelvic exam (examination of vagina, uterus, ovaries and lower abdomen). • The test is done by obtaining a smear containing cells to detect cellular abnormalities (premalignant and malignant) in the cervix and the endocervical canal. • Prior to testing, the patient should be instructed: • NO intercourse • NO use of spermicidal, or female hygiene products for a specific time period before test (time varies: <12 hours, <24 hours)
Determination of due date • EDB = estimated date of birth enables an approximation of how many weeks of pregnancy are left until birth (remaining weeks of gestation) • To estimate how many weeks of gestation • Other acronyms seen: • EDC = estimated date of confinement • EDD = estimated date of delivery • Nagel’s rule: begin with the first day of the last menstrual period, subtract 3 months and add 7 days and then add 1 year to find the EDB
Try these ones for practice……. • LMP: 02.10.10 • EDB: _________ • LMP: 10.25.09 • EDB: _________
What about the reverse? • Date of delivery was 5/10/10 • When was the woman’s LMP? • PS! You don’t have to know this
Is Nagel’s Rule foolproof? • Health care taker needs to take into consideration the following: • If the woman is taking oral contraceptives • If the woman has irregular periods • If the woman has had In Vitro Fertilization (IVF) • Although Nagel’s rule is helpful, it is not always correct • It is based on a regular 28 day cycle • What about the days in a month? 28, 29, 30, 31 • The month is generally based on 30 DAYS
Uterine assessment • During the first 10-12 weeks of pregnancy the uterine size is compatible with the menstrual history. Uterine size may be the single most important clinical method for dating the pregnancy • Technique is done by palpating the uterus (Bi-manual exam is done during the Pelvic exam during the first prenatal visit. However, no external measurements are usually done)
Fundal height • Fundal height may be used as an indicator for uterine size, however this method is less accurate early and very late in pregnancy • McDonald’s method: A centimeter tape measure is used to measure the distance from the top of the symphysis pubis to the top of the uterine fundus • Fundal height in centimeters correlates well with weeks of gestation between 22 to 24 weeks and 34 weeks
Fetal development • Quickening = fetal movement felt by the mother, usually nearing 20 weeks gestation. However, may be felt between 16-22 weeks • Fetal heartbeat = using ultrasonic Doppler, heartbeat is detected between 8-12 weeks gestation • Ultrasound = gestational sac is detected 5-6 weeks after LMP; fetal heart activity by 6-7 weeks, and fetal breathing movement by 10-11 weeks gestation (fetal development SG#1)
Subsequent client history • As pregnancy progresses, the nurse inquires about the preparations the family has made for the new baby • Discomfort • Undesirable exposures, i.e. illness, medical treatment, medications (including OTC), drugs, alcohol • Asses the woman’s psychological needs and emotional status
ONGOING ASSESSMENT is Key!!!!!
Prenatal visits • The recommended frequency of antepartal visits in an uncomplicated pregnancy • Q4 weeks for the first 28 weeks gestation • Q2 weeks until 36 weeks gestation • After week 36, every week until childbirth
Weight gain during pregnancy • Controversial!!!! • The recommended weight gain for women of normal weight pre-pregnancy pregnancy is 25-35 Ibs (11.4-15.9 kg) • Overweight pre-pregnancy: 15-25 Ibs (6.8-11.4 kg) • Underweight pre-pregnancy: gain weight needed to reach their ideal weight plus 25-35 Ibs • The average pattern of weight gain is 3.5-5 Ibs (1.6-2.3 kg) during the first trimester and 12-15 Ibs (5.5-6.8 kg) during each of last two trimesters • KEY!PATTERN of WEIGHT GAIN • Adolescent pregnancy --- a category in itself! (SG#3)
Danger signs in pregnancy What to report immediately:(Detailed coverage in lecture) • Vaginal bleeding: • Abruptio placentae; placenta previa; lesions of cervix or vagina • Sudden gush of fluid from vagina: • Premature rupture of membranes • Abdominal pain: • Premature labor; abruptio placentae • Temperature >38.3C (101F) and chills: • Infection • Dizziness, blurred or double vision, spots before eyes: • Hypertension, preeclampsia
Danger signs in pregnancyContinued…. • Persistent vomiting: • Hyperemesis gravidarum • Severe headache: • Hypertension, preeclampsia • Excessive edema of hands, face, legs, and feet: • Preeclampsia • Muscular irritability, convulsions: • Preeclampsia, eclampsia
Danger signs in pregnancyContinued…. • Epigastric pain: • Preeclampsia, ischemia in major abdominal vessel • Oliguria: • Renal impairment, decreased fluid intake • Dysuria: • Urinary tract infection • Absence of fetal movement: • Maternal medication, obesity, fetal death
Lab values and other measures of importance during pregnancy • Pregnancy screening test: Detection of HCG (Human Chorionic Gonadotropin secreted in early pregnancy by the trophoblast, which stimulates progesterone and estrogen production until the placenta can assume that function) • Urine: usually positive within 10-14 days after first missed menstrual period. * Of note, current urine home pregnancy tests can detect HCG as early as the first day after missed period, but could be a false positive. • Serum: more sensitive than urine & some can indicate ectopic pregnancy. Can actually detect pregnancy up to 5 days BEFORE the first missed period (7-9 days after ovulation & conception), depending on the serum test.
Hemoglobin (Hgb) & Hematocrit (Hct) • Obtained to detect anemia. • Iron deficiency anemia decreases the oxygen carrying capacity of Hgb. • Complications may include prematurity, low birth weight and even fetal death. • Usually during pregnancy, “true” anemia is considered Hct <29% and Hgb <9G/dl. • Of note, an increase (>38-41%) Hct will increase viscosity of blood and increase risk of fetal death
Incompatibilities: Rh factor & ABO • If the Rh factor is present on the surface of erythrocytes (majority of the population), the person is considered Rh+. • If an Rh negative woman is exposed to Rh positive blood (fetus), an antigen-antibody response occurs and the person forms anti-Rh agglutinin. • She is said to be sensitized. • Subsequent exposures to Rh+ blood can cause a serious reaction that results in agglutination and hemolysis of RBC in the fetus.
Rh factor and blood typeEXAMPLE …… • Rh+ father and Rh- mother. • Pregnancy results in Rh+ fetus. • Some Rh+ blood enters the mother’s bloodstream during delivery. • As the placenta separates, the mother is further exposed to the Rh+ blood. • Anti-Rh+ antibodies are formed. • In subsequent pregnancies with an Rh+ fetus, Rh+ RBC are attacked by the anti-Rh+ maternal antibodies, causing hemolysis of the RBC in the fetus. • Hyperbilirubinemia & massive bleeding may occur.
Rh factor & ABOContinued …… • Screening: • Determine maternal blood type (ABO) and Rh factor and do a routine Rh antibody screen (Indirect Coombs’ test) • Indirect Coombs’ (antibody screen) • Test is done on a Rh- woman who might be pregnant with Rh+ fetus to determine if the woman is sensitized (has developed antibodies) to the Rh antigen. • A negative indirect Coombs’ test means the fetus is not at risk (sensitization hasnotoccurred). • A positive indirect Coombs’ test means that sensitizationhasoccurred and the fetus is monitored closely for hemolysis and jaundice • Prevent sensitization by administering immune globulin (RhoGam) at 28 weeks gestation and within 72 hours post-delivery. • Direct Coombs test + other outcomes/treatment: (SG#2 – lecture) • What other times should RhoGam be administered?
ABO Incompatibility • Occurs in about 20-25% of pregnancies but it rarely causes significant hemolysis • Usually occurs in type O mothers with a type A or B fetus • Group O infants have no antigenic sites on the RBC and are therefore never affected regardless of the result of the mother’s blood type • The incompatibility occurs as a result of the interaction of antibodies present in maternal serum and the antigen sites on the fetal red blood cell
ABO Incompatibility (continued) • Unlike Rh incompatibility, the first infant is usually affected • Also unlike Rh incompatibility, antepartal treatment is usually not warranted. • However, as part of the initial assessment, the nurse should note whether the potential for an ABO incompatibility exists (i.e. type O mother and type A or B father). • Following birth, the newborn should be assessed carefully for the development of hyperbilirubinemia.
Other screening tests…. • Serology: • To detect syphilis (may be false positive i.e. if recent viral/bacterial infection, recent vaccinations, hypersensitivity reaction, malaria or TB) • Urine: • If positive for protein, RBC, WBC or cast – may be contaminated or an indication for UTI or renal disease. • If positive for glucose (glucosuria), it could be an indication of diabetes mellitus. • Urine culture is done to detect UTI
Other screening tests…. • Blood glucose: • If hyperglycemia, it is a risk for gestational diabetes (normal range a/t ADA: before meals 70-100, after meals <120). Much more in SG#3 ….. • BP: • Depends on the source, but generally SBP 90-140 & DBP 60-90. • If >140/90, increased risk for preeclampsia (increased vasospasm, CNS irritability leading to convulsions, increased risk of CVA, and increased risk of renal damage). • For the fetus, there is decreased placental perfusion which may lead to preterm labor and low birth weight
TORCH • Group of infectious disease that can cause serious harm to the embryo-fetus: • T=Toxoplasmosis (Toxoplasma gondii) • Test: serology test of antibody titers • O=Other infections • (HIV, HIB, Varicella, parovirus, syphillis) • R=Rubella (German Measles) • Test: serology for rubella titers • C=Cytomegalovirus (CMV) • Belongs to the herpes virus group and causes both congenital and acquired infections referred to as cytomegalic inclusion disease (CID). It can cross the placenta during birth. Test: Urine or serum • H= Herpes Simplex Virus • (Lesions HSV-1 = “above the waist” or HSV-2 = “below the waist”). Test: swab lesions
Diagnostic test • Used in assessing fetal and maternal well-being and potential complications: • Ultrasound: • Intermittent ultrasonic (high frequency sound waves) waves are transmitted and it shows structures of varying density • Amniocentesis: • TRIPLE TEST or now also QUADRUPLE TEST (covered in SG#2) • Obtain amniotic fluid for testing around 16 weeks gestation of • AFP: Increased in NTD and decreased in Trisomy 21 • hCG: Increased in Trisomy 21 • UE3 (unconjugated estriol): Decreased in Trisomy 21 • Diametric Inhibin-A: Very sensitive – increased in Trisomy 21 • This screens for Trisomy 21 (Down’s Syndrome); Trisomy 18 and Neural tube defect (NTD). • It also tests for fetal lung maturity (16-18 weeks gestation)
