Assessing Fetal & Maternal Health
First Prenatal Visit
Prenatal care, essential for ensuring the overall health of newborns and their mothers.
Ideally, begins during the mother’s childhood.
Includes balanced nutrition, adequate immunizations, positive attitudes and education.
Preconceptual Visit
Before becoming pregnant to obtain accurate reproductive life planning.
Physical exam, PAP, CBC, blood type.
Treat any health problems
Choosing a health care provider
clinic
HMO
nurse midwife
obstetrician
family practitioner
Assessment - 1st visit should be a preconception visit for health promotions.
Sometimes 1st visit establishes a baseline.
Nursing Diagnosis
confirm the pregnancy
health seeking behaviors
teratogens
risks to fetus R/T current lifestyle
decisional conflicts with pregnancy
coping
Planning
allow time for a complete history
goals and outcomes
schedule appointments q 4 weeks until 32 weeks then every 2 weeks until 36 weeks then weekly until birth.
Implementation
Establish baseline
Determine gestational age
Monitor fetal development
Identify risks for complications
Prevent problems before they occur
Time for education, answering questions
Evaluation
Focus on woman’s understanding goals and outcomes
Her verbalization of understanding of all information
Major causes of death during pregnancy today are ectopic pregnancy, hypertension, hemorrhage, embolism, infection, anesthesia related complications
First visit includes:
Extensive health history
Complete physical including pelvic exam, blood and urine specimens, pelvic measurements and education.
Interview
provide privacy
when scheduling the appointment caution the woman that it may be a long session
establish your role
provide face to face interview
Components of Health History:
Establish rapport
Gain data on physical and psychosocial health
Obtain basis for anticipatory guidance for the pregnancy
Demographic data
Chief concerns
Family profile
History of past illnesses
History of family illnesses
Day history/social profile
Gynecologic history
Obstetric history
Review of systems
Conclusion
Support Person’s Role:
Partners, children, best friends come to prenatal visits.
Also allow time for privacy at each visit.
Physical Examination:
woman should undress, put on a patient gown, and empty her bladder.
Physical Examination
Obtain urine specimen (clean catch)
bacteriuria, protein, glucose, ketones
VS, height, weight baseline
Assessment of systems:
general appearance and mental status
head and scalp
eyes
nose
ears
sinuses
Assessment of systems
mouth, teeth and throat
neck
lymph nodes
breasts
heart
lungs
back
rectum
extremities and skin
Measurement of Fundal Height/FH
Palpate the fundus at 12 weeks
measure the fundal height
plot on graph
auscultate fetal heart with doppler at 10 to 12 weeks
palpate fetal outline at 28th week
Pelvic Examination:
reveals health information on internal and external reproductive organs.
Equipment - speculum, spatula for cervical
Pelvic Examination
scrapings, glass slide for PAP, culture tube, gloves, lubricant, 2-3 cotton tipped applicators, light and stool.
Support is needed during this exam
External Genitalia
Check for signs of infection, inflammation, irritation, redness, ulceration, discharge or herpes.
Check Skene and Bartholin glands for infection.
Check for rectocele or cystocele.
Internal Genitalia
Cervix - purple if pregnant, check for lesions, ulcerations, or discharge.
Nulligravida - a woman who is not or never has been pregnant. Cervical os is round and small.
In a woman with previous pregnancy the os will be more slitlike.
Pap Smear
Sample from cervical os and vaginal pool.
Vaginal Inspection
Culture for gonorrhea, chlamydia or group B strep
Dark blue to purple color.
Examination of Pelvic Organs
Bimanual exam to assess position, contour, consistency and tenderness of pelvic organs.
Palpate uterus, ovaries and check Hegar’s sign.
Rectovaginal Examination
Assess strength and irregularity of posterior vaginal wall.
Estimating Pelvic Size
pelvic adequacy estimated by week 24 if this is the 1st birth
Types of pelves
Android - male pelvis, the pubic arch forms an acute angle, making the lower dimensions of the pelvis extremely narrow.
Anthropoid - ape like pelvis, the transverse diameter is narrow and the anteroposterior diameter of the inlet is larger than normal.
Gynecoid - normal female pelvis, inlet is well rounded forward and backward, the pubic arch is wide. Ideal for childbirth.
Platypelloid - flattened pelvis, 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 cavity.
Diagonal conjugate - distance between anterior surface of sacral prominence and anterior surface of inferior margin of symphysis pubis.
Most useful measurement for estimation of pelvic size.
Anteroposterior diameter of the pelvic inlet.
Sacral prominence to symphysis pubis.
Pelvimeter
If measurement is more than 12.5 cm it is adequate (average is 9 cm in diameter).
True conjugate or conjugate vera- measurement between the anterior surface of sacral prominence and the posterior surface of the inferior margin of the symphysis pubis.
This is an estimated from the diagonal conjugate.
Depth of the symphysis pubis (1.2 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.
Average is 12.5 cm minus 1.5 or 2 cm, or 10.5 to 11 cm.
Pelvic Examination
Ischial tuberosity - measures is the distance between the ischial tuberosities, or the transverse diameter of the outlet.
The narrowest diameter at that level.
Medial and lowermost aspect of the ischial tuberosities at the level of the anus.
Pelvimeter or ruler is used.
11 cm is adequate because it will allow the widest part of the fetal head, or 9 cm, pass freely through the outlet.
Laboratory Assessment
Blood studies
CBC, H&H and red cell index (anemia), platelet count, sickle cell trait, glucose-6-phosphate dehydrogenase.
VDRL or RPR
Blood typing (include Rh factor)
AFP at 16 to 18 weeks
Indirect Coombs’ test (Rh antibodies) repeat at 28 weeks.
Antibody titers for rubella and hepatitis
Repeat at 36 weeks
Antibodies for varicella
Obtain consent for HIV screening (ELISA) Western blot (Can start AZT).
50-g oral 1-hour glucose loading or tolerance test to R/O diabetes if she has a previous history or symptoms of diabetes.
Urinalysis
test for albuminuria, glycosuria and pyuria.
Tuberculosis Screening
PPD (purified protein derivative) tuberculin test to screen for tuberculosis.
Positive requires a chest X-ray
Ultrasonography
Confirms pregnancy length or document healthy fetal growth.
Risk Assessment