ASSESSING FETAL AND MATERNAL HEALTH:

PRENATAL CARE

Prenatal care, essential for ensuring the Prenatal care, essential for ensuring the overall health of newborns and their mothers, overall health of newborns and their mothers, is a major strategy for helping to reduce the is a major strategy for helping to reduce the number of low-birth weight babies born number of low-birth weight babies born yearly .It is seen as so important that a yearly .It is seen as so important that a number of National Health Goals speak number of National Health Goals speak directly to it. Ideally, prenatal care begins directly to it. Ideally, prenatal care begins during the mother’s childhood. It includes during the mother’s childhood. It includes balanced nutrition with adequate intake of balanced nutrition with adequate intake of calcium and vitamin D during infancy and calcium and vitamin D during infancy and childhood to prevent rickets(which can childhood to prevent rickets(which can distort pelvic size);adequate immunizations distort pelvic size);adequate immunizations against contagious diseases for protection against contagious diseases for protection against viral diseases such as rubella during against viral diseases such as rubella during pregnancy; and a healthy daily diet to ensure pregnancy; and a healthy daily diet to ensure the best state of health possible for a woman the best state of health possible for a woman and her partner when entering pregnancy.and her partner when entering pregnancy.

Nursing process overviewNursing process overviewFor prenatal care:For prenatal care:

1. assessment1. assessment The first prenatal visit is a time to establish baseline data The first prenatal visit is a time to establish baseline data

relevant to health assessment and planning health promotion relevant to health assessment and planning health promotion strategies now and with every subsequent visit. Explaining why strategies now and with every subsequent visit. Explaining why specific assessment data are relevant to the pregnancy maybe the specific assessment data are relevant to the pregnancy maybe the first step in this processfirst step in this process

2.nursing diagnosis2.nursing diagnosis although most woman probably have used a home pregnancy although most woman probably have used a home pregnancy

detection kit to find out if they pregnant, the first prenatal visit detection kit to find out if they pregnant, the first prenatal visit officially serves to confirm this, so nursing diagnosis may focus on officially serves to confirm this, so nursing diagnosis may focus on the response of the woman and her family to that information for the response of the woman and her family to that information for example:example:

Decisional conflict related to desire to be pregnantDecisional conflict related to desire to be pregnant

Risk for ineffective coping related to confirmation of unplanned Risk for ineffective coping related to confirmation of unplanned pregnancy.pregnancy.

Nursing diagnoses appropriate to Nursing diagnoses appropriate to prenatal care in general include:prenatal care in general include:

Health seeking behaviors related Health seeking behaviors related to guidelines for nutrition and activity to guidelines for nutrition and activity during pregnancy.during pregnancy.

Deficient knowledge regarding Deficient knowledge regarding exposure to teratogens during exposure to teratogens during pregnancy.pregnancy.

Risk for injury to fetus related to Risk for injury to fetus related to current lifestyle behaviors.current lifestyle behaviors.

3. 3. Outcome identification and Outcome identification and planningplanning

Sufficient time should be reserved at Sufficient time should be reserved at prenatal visits so they can be thorough, prenatal visits so they can be thorough, allowing enough time to set realistic goals allowing enough time to set realistic goals and expected outcomes with both the and expected outcomes with both the woman and her partner, if desired. Make woman and her partner, if desired. Make sure that a woman leaving an initial sure that a woman leaving an initial prenatal visit schedules an appointment for prenatal visit schedules an appointment for a following visit, as this may not occur to a a following visit, as this may not occur to a woman who may be excited or woman who may be excited or overwhelmed by all the new things that are overwhelmed by all the new things that are happening to her and her family.happening to her and her family.

4. Implementation:4. Implementation: The purposes of prenatal care are to:The purposes of prenatal care are to:

Establish a baseline of the present health.Establish a baseline of the present health. Determine the gestational age of the fetus.Determine the gestational age of the fetus. Monitor fetal developmentMonitor fetal development identify woman at risk for complications.identify woman at risk for complications. Minimize the risk of possible complications by Minimize the risk of possible complications by

anticipating and preventing problems before they anticipating and preventing problems before they occur.occur.

Provide time for education about pregnancy, lactation Provide time for education about pregnancy, lactation and newborn care.and newborn care.

During prenatal visits, much time is spent on teaching During prenatal visits, much time is spent on teaching about prenatal care. It may be helpful to give a woman about prenatal care. It may be helpful to give a woman and her partner pamphlets or books that cover the and her partner pamphlets or books that cover the same topics. This preparation helps to ensure that a same topics. This preparation helps to ensure that a pamphlets advice is consistent with what you have pamphlets advice is consistent with what you have already said and with the views of the woman’s primary already said and with the views of the woman’s primary care physician or nurse-midwife.care physician or nurse-midwife.

5. Outcome evaluation5. Outcome evaluation Evaluation during prenatal visits should Evaluation during prenatal visits should

concentrate on the woman’s initial progress concentrate on the woman’s initial progress toward understanding goals of care for toward understanding goals of care for pregnancy and assessing outcomes established pregnancy and assessing outcomes established for specific diagnoses.for specific diagnoses.

Examples of expected outcomes might Examples of expected outcomes might

include:include: Couple states they have reached a decision Couple states they have reached a decision

about maintaining or discounting the pregnancy.about maintaining or discounting the pregnancy. Client states she feels well informed about the Client states she feels well informed about the

common discomforts of pregnancy and actions common discomforts of pregnancy and actions to take to relieve them.to take to relieve them.

Client lists ways to avoid exposure to teratogens Client lists ways to avoid exposure to teratogens during pregnancy.during pregnancy.

HEALTH PROMOTION DURING HEALTH PROMOTION DURING PREGNANCYPREGNANCY

The Preconceptual Visit: The Preconceptual Visit:

Ideally, women schedule appointments with a physician or Ideally, women schedule appointments with a physician or nurse-midwife before becoming pregnant nurse-midwife before becoming pregnant

TO OBTAIN ACCURATE REPRODUCTIVE LIFE PLANNING TO OBTAIN ACCURATE REPRODUCTIVE LIFE PLANNING INFORMATION, RECEIVE REASSURANCE ABOUT FERTILITY(AS INFORMATION, RECEIVE REASSURANCE ABOUT FERTILITY(AS MUCH AS CAN BE GIVEN BASED ON A HEALTH HISTORY AND MUCH AS CAN BE GIVEN BASED ON A HEALTH HISTORY AND A ROUTINE PHYSICAL EXAMINATION),AND DETECT ANY A ROUTINE PHYSICAL EXAMINATION),AND DETECT ANY PROBLEMS THAT MAY NEED CORRECTION THROUGH HEALTH PROBLEMS THAT MAY NEED CORRECTION THROUGH HEALTH HISTORY, PELVIC EXAMINATION AND PAPANICOLAU(PAP) HISTORY, PELVIC EXAMINATION AND PAPANICOLAU(PAP) TEST.TEST.

At this visit, hemoglobin level and blood type (including Rh At this visit, hemoglobin level and blood type (including Rh

factor) can be determined; minor vaginal infections such as factor) can be determined; minor vaginal infections such as those arising from those arising from CandidaCandida or CHLAMYDIA can be corrected to or CHLAMYDIA can be corrected to help ensure fertility; and the woman can be counseled on the help ensure fertility; and the woman can be counseled on the importance of good protein diet, adequate intake of FOLIC importance of good protein diet, adequate intake of FOLIC ACID, and early prenatal care if she does become pregnant.ACID, and early prenatal care if she does become pregnant.

Choosing a Health Care Choosing a Health Care Provider for Pregnancy and Provider for Pregnancy and

ChildbirthChildbirth Once a woman is or suspects that she may Once a woman is or suspects that she may

be pregnant, she chooses a primary health be pregnant, she chooses a primary health care provider to care for her throughout the care provider to care for her throughout the pregnancy and birth. Various options are pregnancy and birth. Various options are available, INCLUDING A PRENATAL CLINIC, available, INCLUDING A PRENATAL CLINIC, HER HMO HEALTH CARE PROVIDER, A HER HMO HEALTH CARE PROVIDER, A NURSE MIDWIFE, AN OBSTERICIAN, OR A NURSE MIDWIFE, AN OBSTERICIAN, OR A FAMILY PRACTITIONER. FAMILY PRACTITIONER.

Nurses can contribute to the success of Nurses can contribute to the success of prenatal care by listening, counseling, and prenatal care by listening, counseling, and teaching,-three areas of nursing expertise. teaching,-three areas of nursing expertise.

HEALTH ASSESMENT HEALTH ASSESMENT DURING THE FIRST DURING THE FIRST PRENATAL VISIT PRENATAL VISIT

Prenatal care is important because lack of it is Prenatal care is important because lack of it is

associated with the birth of preterm infants and various associated with the birth of preterm infants and various complications for the woman. The major causes of complications for the woman. The major causes of death during pregnancy today for women are ECTOPIC death during pregnancy today for women are ECTOPIC PREGNANCY, HYPERTENSION, HEMORRHAGE, PREGNANCY, HYPERTENSION, HEMORRHAGE, EMBOLISM, INFECTION, AND ANESTHESIA-RELATED EMBOLISM, INFECTION, AND ANESTHESIA-RELATED COMPLICATIONS SUCH AS ANTRAPARTUM CARDIAC COMPLICATIONS SUCH AS ANTRAPARTUM CARDIAC ARREST. An important focus of all prenatal visits, ARREST. An important focus of all prenatal visits, therefore, IS TO SCREEN FOR DANGER SIGNS THAT therefore, IS TO SCREEN FOR DANGER SIGNS THAT MIGHT REVEAL ANY OF THESE CONDITIONS.MIGHT REVEAL ANY OF THESE CONDITIONS.

The first visit includes an extensive health history The first visit includes an extensive health history

complete physical examination, including pelvic complete physical examination, including pelvic examination, and blood and urine specimens for examination, and blood and urine specimens for laboratory work.laboratory work.

THE INITIAL INTERVIEWTHE INITIAL INTERVIEW Interviewing expectant women often elicits contradictory Interviewing expectant women often elicits contradictory

information. Women are likely to want to talk about their information. Women are likely to want to talk about their past health and current pregnancy, so interviewing them past health and current pregnancy, so interviewing them should go smoothly and be productive. On the other hand, should go smoothly and be productive. On the other hand, pregnancy symptoms are subtle, so a woman may not pregnancy symptoms are subtle, so a woman may not regard certain information as important, providing vague regard certain information as important, providing vague answers to questions about these areas. Perhaps she is answers to questions about these areas. Perhaps she is unaware that she is the only person who knows the answers unaware that she is the only person who knows the answers to a number of vital questions-(how do you feel about being to a number of vital questions-(how do you feel about being pregnant? Or have you been taking anything for your pregnant? Or have you been taking anything for your morning nausea?)morning nausea?)

Interviewing is best accomplished in a private, quiet Interviewing is best accomplished in a private, quiet setting. Trying to talk to a woman in a crowded hallway or a setting. Trying to talk to a woman in a crowded hallway or a full waiting room is rarely effective. Pregnancy is too private full waiting room is rarely effective. Pregnancy is too private an affair to be discussed under these circumstances.an affair to be discussed under these circumstances.

It is helpful if the person scheduling the appointment It is helpful if the person scheduling the appointment cautious a woman that the first visit may be long. cautious a woman that the first visit may be long. This prevents her from trying to fit the visit in This prevents her from trying to fit the visit in between other errands or from having to terminate between other errands or from having to terminate the interview because of another appointment.the interview because of another appointment.

Be certain to ask what name a woman wants you to Be certain to ask what name a woman wants you to use when addressing her in a prenatal setting, and use when addressing her in a prenatal setting, and make certain that she knows your name and make certain that she knows your name and understands your role correctly. If she views you as understands your role correctly. If she views you as someone only gathering preliminary data, she will be someone only gathering preliminary data, she will be willing to discuss superficial facts (name, address, willing to discuss superficial facts (name, address, phone number, and the like) but will resist discussing phone number, and the like) but will resist discussing more intimate things (her feelings toward this more intimate things (her feelings toward this pregnancy, the difficulty she has reworking old fears, pregnancy, the difficulty she has reworking old fears, how scared she is about birth).how scared she is about birth).

Because initial health history taking is Because initial health history taking is often time-consuming, a woman may often time-consuming, a woman may be asked to complete some of the be asked to complete some of the forms. Good interviewing technique, forms. Good interviewing technique, however, is important to obtain however, is important to obtain thorough and meaningful health thorough and meaningful health histories. The rapport established by histories. The rapport established by face-to-face interviewing gives a face-to-face interviewing gives a woman the feeling that she is more woman the feeling that she is more than just a client number or chart. It than just a client number or chart. It may be as much a reason she returns may be as much a reason she returns for follow-up care as her desire to be for follow-up care as her desire to be assured that her pregnancy is assured that her pregnancy is progressing normally.progressing normally.

Components of the Health Components of the Health HistoryHistory

An initial interview serves several An initial interview serves several purposes:purposes:

Establishing rapportEstablishing rapport

Gaining information about the woman’s Gaining information about the woman’s physical and psychosocial healthphysical and psychosocial health

Obtaining a basis for anticipatory Obtaining a basis for anticipatory guidance for the pregnancyguidance for the pregnancy

Establishing a baseline health picture Establishing a baseline health picture at the initial pregnancy visit is at the initial pregnancy visit is important. If on subsequent visits a important. If on subsequent visits a symptom is mentioned, you can then symptom is mentioned, you can then check your records to verify that it is check your records to verify that it is truly a new symptom. It may be that truly a new symptom. It may be that the woman is just becoming more the woman is just becoming more aware of it. General interviewing aware of it. General interviewing techniques are discussed in. included in techniques are discussed in. included in the following section are the elements the following section are the elements pertinent to a pregnancy history.pertinent to a pregnancy history.

Demographic DataDemographic Data

Demographic data usually Demographic data usually

obtained include name, age, obtained include name, age, address, telephone number, address, telephone number, religion, and health insurance religion, and health insurance information.information.

Chief ConcernChief Concern

The chief concern is the reason the woman has The chief concern is the reason the woman has come to the health care setting − in this instance, come to the health care setting − in this instance, the fact that she is or thinks she is pregnant.the fact that she is or thinks she is pregnant.

To help confirm pregnancy, inquire about the date To help confirm pregnancy, inquire about the date

her last menstrual period and whether she has had her last menstrual period and whether she has had a pregnancy test or used a home test kit. Elicit a pregnancy test or used a home test kit. Elicit information about the signs of early pregnancy, information about the signs of early pregnancy, such as nausea, vomiting, breast changes, or such as nausea, vomiting, breast changes, or fatigue. Question her about any discomforts of fatigue. Question her about any discomforts of pregnancy, such as constipation, backache, or pregnancy, such as constipation, backache, or frequent urination. Also, ask about any danger frequent urination. Also, ask about any danger signs of pregnancy, such as bleeding, continuous signs of pregnancy, such as bleeding, continuous headache, visual disturbances, or swelling of the headache, visual disturbances, or swelling of the hands and face.hands and face.

Ask if the pregnancy was planned. If you feel Ask if the pregnancy was planned. If you feel uncomfortable asking directly, using a uncomfortable asking directly, using a statement such as, “All pregnancies area bit statement such as, “All pregnancies area bit of surprise. Is that how it was with this one?” of surprise. Is that how it was with this one?” may help provide you with this information. may help provide you with this information. Another way to word such a question would Another way to word such a question would be, “Some couples plan on having children be, “Some couples plan on having children right away; some plan on waiting. How was it right away; some plan on waiting. How was it with you?” If the woman says the pregnancy with you?” If the woman says the pregnancy was not planned, explore to learn if she has was not planned, explore to learn if she has reached a decision about whether to continue reached a decision about whether to continue with the pregnancy. A question such as, with the pregnancy. A question such as, “Some women change their mind about “Some women change their mind about wanting a baby once they realize they are wanting a baby once they realize they are pregnant; some don’t. How has it been for pregnant; some don’t. How has it been for you?” may be effective for obtaining this type you?” may be effective for obtaining this type of information because it says either option is of information because it says either option is possible. You just want her to tell you which is possible. You just want her to tell you which is happening.happening.

Family ProfileFamily Profile

In the past, the social history or family setting In the past, the social history or family setting history (family profile) was left until the end of a history (family profile) was left until the end of a health interview. More often, it is now obtained at health interview. More often, it is now obtained at the beginning of the interview, following the chief the beginning of the interview, following the chief concern. Doing so can help you get to know a concern. Doing so can help you get to know a woman earlier, identify support persons, shape the woman earlier, identify support persons, shape the nature and kind of questions asked, and evaluate nature and kind of questions asked, and evaluate the possible impact of the client’s culture on care. the possible impact of the client’s culture on care.

Ask about marital status. As a rule both married Ask about marital status. As a rule both married and unmarried women want you to know this as and unmarried women want you to know this as they want to alert you if they do not have support they want to alert you if they do not have support people readily available.people readily available.

It is important to know the size of the It is important to know the size of the apartment or house in which a woman apartment or house in which a woman lives because you will be talking with lives because you will be talking with her in the coming months about a her in the coming months about a bedroom or space for a baby’s bed. It bedroom or space for a baby’s bed. It also is important to know whether the also is important to know whether the essential rooms are on the ground floor essential rooms are on the ground floor or upstairs in case she is restricted from or upstairs in case she is restricted from climbing stairs more than once or twice climbing stairs more than once or twice a day during the last part of pregnancy a day during the last part of pregnancy or after birth.or after birth.

Before you can begin to offer a woman any Before you can begin to offer a woman any more than stereotyped health care more than stereotyped health care instruction, get to know her and her sexual instruction, get to know her and her sexual partner’s age(additional testing such as partner’s age(additional testing such as genetic screening may be necessary if she genetic screening may be necessary if she over 35),their educational levels(offers an over 35),their educational levels(offers an estimation of the level of teaching you will estimation of the level of teaching you will plan),and occupation(does the woman’s work plan),and occupation(does the woman’s work involve heavy lifting,long hours of standing in involve heavy lifting,long hours of standing in one position, handling of a toxic substance?)one position, handling of a toxic substance?)

Adaptation to pregnancy is individualized. No Adaptation to pregnancy is individualized. No one in the health care setting will be aware of one in the health care setting will be aware of these potentially harmful situations unless these potentially harmful situations unless questions about family profile are asked.questions about family profile are asked.

History of Past IllnessesHistory of Past Illnesses

Questions about a woman’s past medical history are Questions about a woman’s past medical history are an important part of an interview because a past an important part of an interview because a past condition may become active during or immediately condition may become active during or immediately following pregnancy.following pregnancy.

Representative diseases that can pose a potential Representative diseases that can pose a potential difficulty during pregnancy include kidney disease , difficulty during pregnancy include kidney disease , heart disease(coarctation of the aorta and rheumatic heart disease(coarctation of the aorta and rheumatic fever cause problems most often), hypertension, fever cause problems most often), hypertension, sexually transmitted infection(including hepatitis B sexually transmitted infection(including hepatitis B and human immunodeficiency virus [HIV]), diabetes, and human immunodeficiency virus [HIV]), diabetes, thyroid disease, recurrent seizures, gallbladder thyroid disease, recurrent seizures, gallbladder disease, urinary tract infections, varicosities, disease, urinary tract infections, varicosities, phenylketonuria, tuberculosis, and asthma. phenylketonuria, tuberculosis, and asthma.

It is important to find out whether a woman had It is important to find out whether a woman had childhood disease such as chickenpox(varicella), childhood disease such as chickenpox(varicella), mumps(epidemic parotitis), measles (rubeola), mumps(epidemic parotitis), measles (rubeola), German measles (rubella), or poliomyelitis. From German measles (rubella), or poliomyelitis. From this information, you can estimate the degree of this information, you can estimate the degree of antibody protection the client has against these antibody protection the client has against these diseases if she is exposed to them during her diseases if she is exposed to them during her pregnancy. pregnancy.

While pregnant she can be immunized against While pregnant she can be immunized against poliomyelitis by the Salk(killed virus) vaccine. poliomyelitis by the Salk(killed virus) vaccine. However she cannot be immunized against the However she cannot be immunized against the other diseases because the vaccines against these other diseases because the vaccines against these contain live viruses, as does the oral Sabin contain live viruses, as does the oral Sabin poliomyelitis vaccine. Live virus vaccines could be poliomyelitis vaccine. Live virus vaccines could be harmful to the fetus if the virus crossed the harmful to the fetus if the virus crossed the placenta.placenta.

Also ask about any allergies, including Also ask about any allergies, including any drug sensitivities. As a rule any drug sensitivities. As a rule women with allergies of any women with allergies of any magnitude should be urged to breast-magnitude should be urged to breast-feed rather than bottle feed their feed rather than bottle feed their infants to avoid possible milk allergy infants to avoid possible milk allergy in the infant. Any past surgical in the infant. Any past surgical procedures are also important procedures are also important because adhesions resulting from past because adhesions resulting from past abdominal surgery may interfere with abdominal surgery may interfere with uterine growth.uterine growth.

HISTORY OF FAMILY HISTORY OF FAMILY ILLNESSESILLNESSES

A family history documents illnesses A family history documents illnesses that occur frequently in the family and that occur frequently in the family and helps to identify potential problems in helps to identify potential problems in the mother during pregnancy or in the the mother during pregnancy or in the infant at birth ask specifically about infant at birth ask specifically about cardiovascular and renal disease cardiovascular and renal disease cognitive impairment, blood disorders, cognitive impairment, blood disorders, or any known genetically inherited or any known genetically inherited diseases or congenital anomalies.diseases or congenital anomalies.

DAY HISTORY/SOCIAL DAY HISTORY/SOCIAL PROFILEPROFILE

Nutrition is an important part of a day history to a Nutrition is an important part of a day history to a obtain, particularly in light of the number of young obtain, particularly in light of the number of young adults with eating disorders today. A “24-hour recall” adults with eating disorders today. A “24-hour recall” is helpful to obtain accurate nutrition information is helpful to obtain accurate nutrition information because by doing this, the woman tells you what she because by doing this, the woman tells you what she actually ate, not what she should have eaten.actually ate, not what she should have eaten.

Ask about the type, amount, and frequently of Ask about the type, amount, and frequently of exercise to determine her routine pattern and exercise to determine her routine pattern and whether it will be consistent with a recommended whether it will be consistent with a recommended level for pregnancy. If she hikes or camps, she is risk level for pregnancy. If she hikes or camps, she is risk for exposure to Lyme disease. Ask about hobbies. for exposure to Lyme disease. Ask about hobbies. Certain hobbies, such as working with lead-based Certain hobbies, such as working with lead-based glazes and ceramics, might not be wise to continue glazes and ceramics, might not be wise to continue during pregnancy because lead is teratogenic.during pregnancy because lead is teratogenic.

Because smoke, whether first-hand or second-Because smoke, whether first-hand or second-hand, has been shown to be harmful to fetal hand, has been shown to be harmful to fetal growth, obtain information about the client’s growth, obtain information about the client’s smoking habits. Excessive alcohol intake can lead smoking habits. Excessive alcohol intake can lead to poor nutrition, can be directly responsible for to poor nutrition, can be directly responsible for fetal alcohol syndrome, and may cause preterm fetal alcohol syndrome, and may cause preterm birth. If a woman answers vaguely about how she birth. If a woman answers vaguely about how she smokes or drinks alcohol (“I drink socially” or “I smokes or drinks alcohol (“I drink socially” or “I only smoke occasionally), attempt to determine only smoke occasionally), attempt to determine exactly what she means so you can more exactly what she means so you can more accurately evaluate the frequency of these accurately evaluate the frequency of these events.events.

Pregnant women, especially adolescents, are at an Pregnant women, especially adolescents, are at an increased risk for intimate partner abuse. Ask increased risk for intimate partner abuse. Ask enough questions to be certain the woman is not enough questions to be certain the woman is not involved in an abusive partnership.involved in an abusive partnership.

A medication history is also important. Ask A medication history is also important. Ask whether the woman takes any medications, whether the woman takes any medications, prescribed or over-the-counter, because their prescribed or over-the-counter, because their effect on a growing fetus will have to be effect on a growing fetus will have to be evaluated. This also includes any herbal evaluated. This also includes any herbal preparations that a woman might be using. For preparations that a woman might be using. For example, isotretinoin (accutane), a vitamin A example, isotretinoin (accutane), a vitamin A preparation taken for acne, is associated with preparation taken for acne, is associated with spontaneous miscarriage and congenital spontaneous miscarriage and congenital anomalies. Herbal supplements should be anomalies. Herbal supplements should be evaluated carefully before being taken by evaluated carefully before being taken by pregnant women to be certain they don’t pregnant women to be certain they don’t stimulate uterine contractions.stimulate uterine contractions.

Ask about the use of any recreational drugs, Ask about the use of any recreational drugs, such as marijuana or cocaine, as these also can such as marijuana or cocaine, as these also can be deleterious to fetal growth. Include be deleterious to fetal growth. Include intravenous drug use because of the increased intravenous drug use because of the increased risk for exposure to HIV or hepatitis B.risk for exposure to HIV or hepatitis B.

GYNECOLOGIC HISTORYGYNECOLOGIC HISTORY

Obtain information about her age of menarche Obtain information about her age of menarche (first menstrual period) and how well she was (first menstrual period) and how well she was prepared for it as a normal part of life. Ask about prepared for it as a normal part of life. Ask about her usual cycle, including the interval, duration, her usual cycle, including the interval, duration, amount of menstrual flow, and any discomfort she amount of menstrual flow, and any discomfort she feels. If she describes menstrual cramps as feels. If she describes menstrual cramps as “horrible” and wonders “how I live through them “horrible” and wonders “how I live through them some months”, anticipate the need for additional some months”, anticipate the need for additional counseling to help her prepare for labor.counseling to help her prepare for labor.

Anticipate their need for counseling in the Anticipate their need for counseling in the postpartum period about active ways to relieve postpartum period about active ways to relieve their menstrual discomfort when their periods their menstrual discomfort when their periods resume.resume.

Also ask if a woman does a monthly perineum self Also ask if a woman does a monthly perineum self examination to evaluate her interest in self-care examination to evaluate her interest in self-care routine. Breast self-examination is no longer thought routine. Breast self-examination is no longer thought to yield enough reliable information to be continued to yield enough reliable information to be continued as a self-care routine.as a self-care routine.

Ask about past surgery on the reproductive tract. If Ask about past surgery on the reproductive tract. If she has had uterine surgery, a cesarean birth may be she has had uterine surgery, a cesarean birth may be necessary because her uterus may not be able to necessary because her uterus may not be able to expand and contract as efficiently as usual because of expand and contract as efficiently as usual because of the surgical scar.the surgical scar.

Ask also about what reproductive planning methods, if Ask also about what reproductive planning methods, if any, have been used. Occasionally, a woman may any, have been used. Occasionally, a woman may become pregnant with an intrauterine device (IUD) in become pregnant with an intrauterine device (IUD) in place. If this occurs, it will be removed to prevent place. If this occurs, it will be removed to prevent infection during pregnancy. Be certain to include a infection during pregnancy. Be certain to include a sexual history, including the number of sexual sexual history, including the number of sexual partners and use of safe sex practices, to establish the partners and use of safe sex practices, to establish the woman’s risk for contracting a sexually transmitted woman’s risk for contracting a sexually transmitted infection.infection.

As a part of any woman’s gynecologic history, As a part of any woman’s gynecologic history, assess for the possibility of stress incontinence assess for the possibility of stress incontinence (incontinence of urine on laughing, coughing, (incontinence of urine on laughing, coughing, deep inspiration, jogging, or running). deep inspiration, jogging, or running).

Commonly, weakness occurs from difficult Commonly, weakness occurs from difficult births, the birth of large infants, grand births, the birth of large infants, grand multiparity, and instrumented births. During multiparity, and instrumented births. During pregnancy stress incontinence can become pregnancy stress incontinence can become intensified from the increasing abdominal intensified from the increasing abdominal pressure.pressure.

Women can relieve stress incontinence to Women can relieve stress incontinence to some degree by strengthening the perineal some degree by strengthening the perineal muscles with the use of Kegel exercises.muscles with the use of Kegel exercises.

OBSTETRIC HISTORYOBSTETRIC HISTORY

For each previous pregnancy, document the child’s For each previous pregnancy, document the child’s sex and the place and date of birth. Review the sex and the place and date of birth. Review the pregnancy briefly:pregnancy briefly:

Was it planned?Was it planned? Did she have any complications, such as spotting, Did she have any complications, such as spotting,

swelling of her hands or feet, falls, or surgery?swelling of her hands or feet, falls, or surgery? Did she take any medication? If so, what and why?Did she take any medication? If so, what and why? Did she receive prenatal care? When did she start?Did she receive prenatal care? When did she start? What was the duration of the pregnancyWhat was the duration of the pregnancy What was the duration of labor?What was the duration of labor? Was labor what she expected? Worse? Better?Was labor what she expected? Worse? Better? What was the type of birth?What was the type of birth? What type of anesthesia, if any, was used?What type of anesthesia, if any, was used?

Did she have stitches following birth?Did she have stitches following birth? Did she have any complications, such as Did she have any complications, such as

excessive bleeding or infection following excessive bleeding or infection following the birth?the birth?

What was the infant’s birthweight and sex?What was the infant’s birthweight and sex? What was the condition of the infant at What was the condition of the infant at

birth? Did the infant cry right away?birth? Did the infant cry right away? What was the infant’s Apgar score?What was the infant’s Apgar score? Was any special care needed for the baby, Was any special care needed for the baby,

such as suctioning, oxygen, or an such as suctioning, oxygen, or an incubator?incubator?

Was the baby discharged from the health Was the baby discharged from the health care setting with her?care setting with her?

What is the child’s present state of health?What is the child’s present state of health? How was the pregnancy overall for her?How was the pregnancy overall for her?

Ask about any previous miscarriages or Ask about any previous miscarriages or abortions and whether she had any abortions and whether she had any complications during or following them. If complications during or following them. If the woman’s blood type is Rh negative, the woman’s blood type is Rh negative, ask if she received Rh immune globulin ask if she received Rh immune globulin (RhiG[RhoGAM]) after miscarriages or (RhiG[RhoGAM]) after miscarriages or abortions or previous births so you will abortions or previous births so you will know whether Rh sensitization could have know whether Rh sensitization could have occurred. occurred.

Ask if she has ever had a blood transfusion Ask if she has ever had a blood transfusion to establish possible risk of hepatitis B or to establish possible risk of hepatitis B or HIV exposure or Rh sensitization.HIV exposure or Rh sensitization.

After a history of previous pregnancies is After a history of previous pregnancies is obtained, determine the woman’s status with obtained, determine the woman’s status with respect to the number of times she has been respect to the number of times she has been pregnant, including the present pregnancy pregnant, including the present pregnancy ((gravidagravida), and the number of children and the ), and the number of children and the number of children above the age of viability number of children above the age of viability she has previously born (she has previously born (parapara).).

Age of viability- Age of viability- is the earliest age at which is the earliest age at which fetuses could survive if they were born at that fetuses could survive if they were born at that time, generally accepted as 24 weeks, or time, generally accepted as 24 weeks, or fetuses weighing more than 40 g.fetuses weighing more than 40 g.

GravidaGravida- a woman who is or has been - a woman who is or has been pregnant.pregnant.

ParaPara- the number of pregnancies that reached - the number of pregnancies that reached viability, regardless of whether the infants were viability, regardless of whether the infants were born alive or not.born alive or not.

A more comprehensive system for classifying A more comprehensive system for classifying pregnancy status (GTPAL or GTPALM) provides pregnancy status (GTPAL or GTPALM) provides greater detail on a woman’s pregnancy history. greater detail on a woman’s pregnancy history. By this system, the gravida classification By this system, the gravida classification remains the same, but para is broken down into:remains the same, but para is broken down into:

T:T: The number of full-term infants born (infants The number of full-term infants born (infants born at 37 weeks or after)born at 37 weeks or after)

P:P: The number of preterm infants born (infants The number of preterm infants born (infants born before 37 weeks)born before 37 weeks)

A:A: The number of spontaneous or induced The number of spontaneous or induced abortions.abortions.

L: L: The number of living children.The number of living children. M: M: Multiple pregnancies.Multiple pregnancies.

REVIEW OF SYSTEMSREVIEW OF SYSTEMS A review of systems completes the subjective A review of systems completes the subjective

information. Use a systematic approach, such as head information. Use a systematic approach, such as head to toe, and explain what you’ll be doing.to toe, and explain what you’ll be doing.

The following body systems and questions about The following body systems and questions about

conditions constitute the minimum information to be conditions constitute the minimum information to be addressed in a review of systems for a first prenatal addressed in a review of systems for a first prenatal visit:visit:

Head:Head: Headache? Head injury? Seizures? Dizziness? Headache? Head injury? Seizures? Dizziness? Fainting?Fainting?

Eyes:Eyes: Vision? Glasses needed? Diplopia? Infection? Vision? Glasses needed? Diplopia? Infection? Glaucoma? Cataract? Pain? Recent changes?Glaucoma? Cataract? Pain? Recent changes?

Ears:Ears: Infection? Discharge? Earache? Hearing loss? Infection? Discharge? Earache? Hearing loss? Tinnitus? Vertigo?Tinnitus? Vertigo?

Nose:Nose: Epistaxis (nose bleeds)? Epistaxis (nose bleeds)? Discharge? How many colds a Discharge? How many colds a year? Allergy? Postnatal year? Allergy? Postnatal drainage? Sinus pain?drainage? Sinus pain?

Mouth and Pharynx:Mouth and Pharynx: Dentures? Condition of teeth? Dentures? Condition of teeth? Tootaches? Any bleeding of Tootaches? Any bleeding of gums? Hoarseness? Difficulty in gums? Hoarseness? Difficulty in swallowing? Tonsillectomy?swallowing? Tonsillectomy?

Neck:Neck: Stiffness? Masses? Stiffness? Masses?

Breasts:Breasts: Lumps? Secretion? Pain? Lumps? Secretion? Pain? Tenderness?Tenderness?

Respiratory system:Respiratory system: Cough? Wheezing? Cough? Wheezing? Asthma? Shortness of breath? Pain? Serious Asthma? Shortness of breath? Pain? Serious chest illness, such as tuberculosis or chest illness, such as tuberculosis or pneumonia?pneumonia?

Cardiovascular system:Cardiovascular system: History of heart History of heart murmur? History of heart disease such as murmur? History of heart disease such as rheumatic fever or Kawasaki Disease? rheumatic fever or Kawasaki Disease? Hypertension? Any pain? Palpitations? Hypertension? Any pain? Palpitations? Anemia? Does she know her blood Anemia? Does she know her blood pressure? Has she ever had a blood pressure? Has she ever had a blood transfusion?transfusion?

Gastrointestinal System:Gastrointestinal System: What was her What was her prepregnency weight? Vomiting? Diarrhea? prepregnency weight? Vomiting? Diarrhea? Constipation? Change in bowel habits? Constipation? Change in bowel habits? Rectal pruritus? Hemorrhoids? Pain? Ulcer? Rectal pruritus? Hemorrhoids? Pain? Ulcer? Gallbladder disease? Hepatitis? Gallbladder disease? Hepatitis? Appendicitis?Appendicitis?

Genitourinary System:Genitourinary System: Urinary Tract Urinary Tract Infection? Hematuria? Frequent urination? Infection? Hematuria? Frequent urination? Sexually Transmitted infection? Pelvic Sexually Transmitted infection? Pelvic inflammatory disease? Hepatitis B? HIV? inflammatory disease? Hepatitis B? HIV?

Extremities:Extremities: Varicose veins? Pain or Varicose veins? Pain or stiffness of joints? Any fractures or stiffness of joints? Any fractures or dislocations?dislocations?

Skin:Skin: Any rashes? Acne? Psoriasis? Any rashes? Acne? Psoriasis?

CONCLUSIONCONCLUSION

End an interview by asking if End an interview by asking if there is something you have not there is something you have not covered that the woman wants covered that the woman wants to discuss. This gives her one to discuss. This gives her one more chance to ask any more chance to ask any questions she has about this new questions she has about this new life experience.life experience.

SUPPORT PERSON’S ROLESUPPORT PERSON’S ROLE

If family members are present, should If family members are present, should they be included in an initial interview? they be included in an initial interview? As a whole, interviewing is most effective As a whole, interviewing is most effective if it’s one-to-one interaction.if it’s one-to-one interaction.

If childbearing is to be a family affair, If childbearing is to be a family affair, however, it is important to determine the however, it is important to determine the partner’s degree of acceptance of the partner’s degree of acceptance of the pregnancy and of assuming a new pregnancy and of assuming a new parenting role.parenting role.

Interviewing the woman alone and then Interviewing the woman alone and then inviting the support person and family inviting the support person and family to join her while you talk about to join her while you talk about pregnancy symptoms with them as a pregnancy symptoms with them as a family is an effective solution. Providing family is an effective solution. Providing some private interview time with the some private interview time with the partner allows the partner to express partner allows the partner to express any concerns or worries.any concerns or worries.

After the confirmation of pregnancy, After the confirmation of pregnancy, the partner should be included when the partner should be included when health care information is given.health care information is given.