PRENATAL ASSESSMENT: GUIDELINES FOR ASSESSMENT AND CARE OF THE PREGNANT WOMAN INTRODUCTION The major goal of prenatal

care is to ensure the birth of a healthy baby with minimal risk for the mother. There are several components involved in achieving this objective:
y y y y y

Early, accurate estimation of gestational age Identification of the patient at risk for complications Ongoing evaluation of the health status of both mother and fetus Anticipation of problems and intervention, if possible, to prevent or minimize morbidity Patient education and communication

INITIAL PRENATAL VISIT: Key Points

y y y y y y

Provide time for a longer office visit, for example, 45 minutes Have patient come in early & complete paper work Help patient feel comfortable Begin interview with patient fully clothed Sit down & make eye contact First visit is preferred at 6 weeks gestation (6-8 weeks)

THOROUGH MEDICAL HISTORY: Key points

y y

Important, as with any initial health care visit Attitudes can indicate future parent-child relationship risk factors: y y How does the patient feel about the pregnancy? Was the pregnancy planned

Underlying medical problems need to be identified, especially: y Diabetes

y y y y y y y

Hypertension Renal disease Hemoglobinopathy Isoimmunization STDs Significant other infections

All components of PMH are important, especially y y y y y y y y y Age Last pelvic exam and pap smear Menstrual history Previous pregnancies, abortions, miscarriages, deliveries Birth control (methods used) Fertility infertility issues Anesthesia issues or reactions Pelvic injury Medications: prescription, OTC & complimentary therapies y y Allergies reactions Emphasize need to communicate all medications considered during pregnancy y y y Social & home environment influences Life-style issues: diet, exercise, sleep, drugs, alcohol, smoking ROS: pre-pregnancy weights & baselines

COMMON SYMPTOMS OF PREGNANCY TO CONSIDER: Key points

Amennorrhea: y Results from high levels of hormones: estrogen, progesterone & hCG (human chorionic gonadotropin) y Currently used pregnancy tests are based on amount of hCG in blood or urine, with hCG present as early as 8 days after fertilization y Depending on the specific test used, concentrated urine improves pregnancy detection rate of urine to equal that of serum testing y y Test may be positive as early as 3-4 days after implantation 98% of test results are positive within 7 days after implantation

Nausea or morning sickness of pregnancy : y y y Most common between 8-14 weeks gestation Hypersensitivity to odors may develop Severe vomiting may result in dehydration or ketosis

Breast Changes: y y y y y Increased tenderness Increased vascularity & sense of heaviness Nipples more erectile, with increased pigmentation Raised Montgomery s tubercles on areola Colostrum secreted by 16th week

Heartburn: y y y Relaxation of gastroesophageal sphincter Upward displacement of stomach due to uterine enlargement Digestions delays, due to decreases in gastric mobility & gastric acid

Backache: y y y y Increased hormone secretions (estrogen & progesterone) Increased pelvic relaxation Loss of abdominal muscle tone Increased uterine weight

Abdominal Enlargement: y Uterus rises out of pelvis into abdomen by 12th week of gestation

Quickening: y Usually felt at 20 weeks in primigravida, but earlier in multipara

Skin Changes: y Hyperpigmentation

y y y y y y

Linea alba darkens to linea nigra Chloasma pigmentation of face Stretch Marks or striae gravidarum Nail changes increased grooving, brittleness or softening Increased sweating Hirsutism

Urinary Changes: y Increased frequency due to uterine pressure in early & late pregnancy

Vaginal Discharge: y Increased asymptomatic, white, milky cervical mucous & vaginal discharge

Fatigue: y Common in early pregnancy

Headaches: y Common, especially around 16 20 weeks gestation

Other symptoms: y y y y Varicose veins Leg cramps Edema of legs & hands Constipation

y y y

Bleeding gums Insomnia Dizziness

THOROUGH PHYSICAL EXAMINATION

Objectives: y y y Evaluate health of mother & fetus Determine gestational age of fetus Initial plan of care

Measurements & Vital Signs: y y Height & Weight Baseline vital signs & BP

Skin changes:

choasma of face

Teeth & Gums: check for hypertrophy of gums (increased vascularity)

Thyroid: symmetrical enlargement (R/O goiter)

Heart & Lungs: (In later stages of pregnancy): y PMI elevated & lateral in 3rd trimester

Non-pathological systolic flow murmurs develop Diastolic murmur is always pathological

Breasts & Nipples: Note expected changes y y Everted nipples indicate possible interference with breast feeding Discrete masses are considered pathological

Abdomen: y y y y y Contour Skin changes: linea nigra, striae gravidarum Fetal movement (felt by 24 weeks) Uterine size & fundal height Fetal Heart Rate (FHR): (120-160 per minute) Fetal Heart Tones audible with Doppler, from 11-13 weeks gestation

Genitalia

y y y y

External genitalia & anus: lesions & varicosities Vaginal leukorrhea Adenexal areas: corpus luteum cyst-like enlargment Bimanual & pelvic measurements

COMMON SIGNS OF EARLY PREGNANCY

Sign

Finding

Gestational Age

Goodell Hegar McDonald Chadwick

softening of cervix softening of uterine isthmus fundus flexes easily on cervix bluish color or cervix, Vagina & vulva

4-6 weeks 6-8 weeks 7-8 weeks

8-12 weeks

Extremities: y y Varicosities Edema

INITIAL DISCUSSIONS WITH PATIENT

Expected weight gain y Ideal: 25-30 pounds total

y y

2 pounds per month:

1st & 2nd trimester

1 pound per week average: last trimester

Exercise and activity levels y y y Varies with physical conditioning of patient Contact sports not recommended Core temperature elevations about 101.5 may be harmful to fetus

Diet

Prenatal appointment schedule: y y y Monthly: up to 32 weeks gestation Every 2 weeks from 32 to 36 weeks Every week from 36 to 40 weeks

Expected changes of pregnancy & selected important things to know

Prenatal Vitamins: y Maternal ingestion of 0.4 0.8 mg of Folic Acid per day reduces the occurrence of fetal neuronal tube defect y y Most prenatal vitamins contain 1 mg of folic acid Prenatal vitamins with folic acid are often recommended for non-pregnant women of child-bearing age who are planning pregnancy

Calculating the Due Date or Expected Date of Confinement (EDC) Last menstrual period (LMP)

LMP less 3 months Add 1 year + 7 days = EDC

Or

Nagele s Rule: LMP Add 9 months + 7 days = EDC

A Prenatal Flow Sheet for recording visits is through & efficient

MILESTONE LABORATORY TESTS

Routine, mandatory: completed at first visit

CBC: UA:

detects anemia, hemoglobinopathies, infections baseline for protein, glucose: r/o diabetes, renal disease, hypertensive disease of pregnancy

ABO & Rh typing

checks compatibility of maternal-fetal blood types & need for Rhogam

Rubella titer

determine presence or absence of maternal Antibodies (Rubella causes blindness, heart & hearing abnormalities in fetus)

Pap smear HBsAg

Screens for cervical intraepithelial dysplasia or neoplasia Hepatitis B surface antigen. Virus infects fetus, may cause fetal anomalies

VDRL

or RPR: screens for syphilis, which infects fetus, causing congenital anomalies

Highly recommended lab screening (not mandatory) at first visit:

STD smears/cultures

Gonorrhea, Chlamydia, Herpes Generally cause eye infections & blindness, repiratory infections & other infections of newborns. Active herpes near due date indicates need for C-section birth

HIV

requires permission, and signed informed consent by patient

MILESTONE LAB TESTS & PROCEDURES SCHEDULED LATER IN PREGNANCY

16-18 Weeks:

Ultrasound:

most accurate for dating pregnancy

Not mandatory, but most commonly done

17-21 Weeks: (when standardized values for this test are most accurate) Alpha Fetal Protein (AFP) Medical-legal point: Important to offer this test, and document that it was offered

It is not mandatory in the sense that the patient can refuse High levels may indicate neuronal tube defects in the fetus Low values (not as predictive) may be indicative of trisomy 21 &other trisomy defects Triple Screen: may be used, and combines the following: AFP SerumEstriol HCG

24-28 Weeks:

50 Gram Glucose Tolerance Test (glucose challenge)

H & H: may repeat at 28 weeks (especially with anemia)

28-36 Weeks

Beta Hemolytic Streptococcus Screen Collect culture swabs from vaginal introitus (not cervix) If positive, mother must be treated before delivery to prevent fetal sepsis

EVERY OB VISIT Monitor: y y weight, BP temp, UA for protein & glucose (dip stick UA), Lower renal threshold in pregnancy 2+ or greater UA protein could signal pregnancy induced hypertension (PIH) y y Serum glucose screen Fundal height: measured from top of pubic bone to top of uterine fundus Measurement is most accurate from 20-36 weeks gestation Each 1 cm increase indicates one additional week of gestation y y Edema: dependent edema from pressure on inferior vena cava & iliac veins Nausea & vomiting: most prominent from 8-14 weeks gestation

y y

Pain & contractions Fetal movements Discuss this at 16 weeks & ask patient to record when fetal movements are felt (usually between 17-18 weeks)

y y

Bleeding or discharge Recent illness & concerns

MEASURING UTERINE SIZE

y y y y

Nulliparous uterus: 8 weeks gestation (or if second baby): 10 weeks: 12 weeks: Palpable just above symphysis pubis

golf ball size hand ball size baseball size soft ball size

y y

12-14 weeks: 16 weeks:

uterus rises up into abdominal cavity fundus palpable halfway between symphysis & umbilicus

y y y y

20 weeks: 28 weeks: 34 weeks: 38-40 weeks :

fundus at umbilicus (lower border) fundus halfway between umbilicus & xiphoid fundus just below xiphoid fundus drops (lightening)

MILESTONES TO MONITOR ON SUBSEQUENT OB VISITS

Fetus: y y FHT with Doppler: 12 weeks Quickening: 16-19 weeks (ask patient to keep track of movements) y y Primipara Multipara (later, about 18-19 weeks) (sooner, about 16 weeks)

16-18 Weeks: y y Ultrasound Offer AFP or Triple Screen: 17-21 weeks

24-28 Weeks: y y y 50 Gm Glucose Tolerance Test (glucose challenge) May repeat H&H at 28 weeks (anemia vs hemodilution) Rhogam given if Rh negative

32 Weeks: y Encourage to enroll in Lamaze classes

36 Weeks: y y y y Talk about when to go to the hospital What to do if water breaks Mucous plug Analgesia, anesthesia, epidural

y y y y y y y y

Conduct of labor Need to IV access Episiotomy Post natal contraception Tour of birth center Practitioner for infant medical care Circumcision Feeding: breast bottle

PELVIMETRY: Key Points

Initial considerations y y y y y Pelvic shape Diagonal conjugate Obstetrical conjugate Angle of subpubic arch Coccyx

Pelvic shapes

Gynecoid (50% of women): Pelvic outlet is round & pubic arch is wide Ancticipated delivery is vaginal, spontaneous

Android (25% of women):

Pelvis outlet is heart shaped & pubic arch is narrow Anticipated delivery could be vaginal with forceps or cesarean y Anthropoid (24% of women): Pelvic outlet is vertically oval & pubic arch is narrow Anticipated delivery is vaginal, possible forceps y Platypelloid (3% of women): Pelvic outlet is transversely oval & pubic arch is wide Anticipated delivery is vaginal, sponanteous

Diagonal conjugate

y y

One of the most import measurements of AP diameter of pelvic inlet 12.5 13 cm measurement from the inferior border of the symphysis pubis to sacral promontory

Obstetric conjugate

Also measured the AP diameter of the pelvic inlet, more accurately obtained by x-ray

Diagonal conjugate minus 1.5 2 cms from the posterior board of The symphysis pubis to the sacral promontory

Angle of pubic arch or subpubic arch

Estimation of angle of subpubic arch is done by using both thumbs, & examiner externally traces descending rami down to

ischia tuberosities y A wide pubic arch (105 degrees or more) accommodates spontaneous vaginal delivery y A narrow pubic arch (less than 90 degrees) indicates a more difficult Delivery, with use of forceps or suction, or a cesarean section

Coccyx

When palpated during bimanual examination, a prominent inward pointing coccyx could indicate possible problems with vaginal delivery

COMMON CLINICAL URGENT PATHOLOGICAL CONDITIONS

First trimester bleeding:

consider normal implantation of ovum,

cervicitis, vaginal varicosities, threatened abortion (ectopic pregnancy, especially with abdominal pain) y Second semester bleeding: abruptio placenta or placenta previa

Postpartum hemmorage:

blood loss over 500 ml during first

24 hours after delivery

Pseudocesis:

false pregnancy (psychiatric considerations)

Prenatal care (also known as antenatal care) refers to the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to appropriate specialists, hospitals, etc. if necessary. The availability of routine prenatal care has played a part in reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable infant problems. Animal studies indicate that mothers' (and possibly fathers') diet, vitamin intake, and glucose levels prior to ovulation and conception have long-term effects on fetal growth and adolescent and adult disease.[1] While availability of prenatal care has considerable personal health and social benefits, socioeconomic problems prevent its universal adoption in many developed as well as developing nations. One prenatal practice is for the expecting mother to consume vitamins with at least 400 mcg of folic acid to help prevent neural tube defects. Prenatal care generally consists of:
y y y y

monthly visits during the first two trimesters (from week 128) biweekly from 28 to week 36 of pregnancy weekly after week 36 (delivery at week 3840) Assessment of parental needs and family dynamic

Contents [hide]
y y y

y y

1 Physical examination 2 Ultrasound 3 Prenatal Care and Race in the USA o 3.1 Consequences of Minorities Limited Access to Prenatal Care o 3.2 Prenatal Care and the Latina Paradox o 3.3 Prenatal Care Improvements for Minorities 4 References 5 External Links

[edit] Physical examination Physical examinations generally consist of:

y y y y y y y

Collection of (mother's) medical history Checking (mother's) blood pressure (Mother's) height and weight Pelvic exam Doppler fetal heart rate monitoring (Mother's) blood and urine tests Discussion with caregiver

[edit] Ultrasound Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:

y y y y y y y y

Diagnose pregnancy (uncommon) Check for multiple fetuses Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition) Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists) Determine if an intrauterine growth retardation condition exists Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones) Check the amniotic fluid and umbilical cord for possible problems Determine due date (based on measurements and relative developmental progress)

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:
y y y y

7 weeks confirm pregnancy, ensure that it's neither molar or ectopic, determine due date 1314 weeks (some areas) evaluate the possibility of Down Syndrome 1820 weeks see the expanded list above 34 weeks (some areas) evaluate size, verify placental position

[edit] Prenatal Care and Race in the USA Many health professionals consider prenatal care a nearly essential practice for pregnant women; however, there are wide gaps in the American population regarding who has access to these services and who actually utilizes these services. For example, African-American expectant mothers are 2.8 times as likely as non-Hispanic white mothers to begin their prenatal care in the third trimester, or to receive no prenatal care during the entirety of the pregnancy.[2] Similarly, Hispanic expectant mothers are 2.5 times as likely as non-Hispanic white mothers to begin their prenatal care in the third trimester, or to receive no prenatal care at all.[3] The following factors impact a womans likelihood of acquiring prenatal care:
y

Health Insurance: 13% of women who become pregnant every year in the United States are uninsured, resulting in severely limited access to prenatal care. According to Childrens Defense Funds website, Almost one in every four pregnant Black women and more than one in three pregnant Latina women is uninsured, compared with one in nearly seven pregnant White women. Without coverage, Black and Latina mothers are less likely to access or afford prenatal care.[4] Currently, pregnancy is considered a pre-existing condition, making it much harder for uninsured pregnant women to actually be able to afford private health insurance.[5] Formal Education: Oftentimes, Black and Hispanic pregnant women have fewer years of formal education, which sparks a large domino effect of consequences related to prenatal care. A lack of formal education results in less knowledge about pregnancy appropriate prenatal healthcare as a whole, fewer job opportunities, and a lower level of income throughout their adult life.[6] Trust & Comfort with Healthcare Industry: Many minority women have limited experience with the healthcare industry on a whole, as compared to their Caucasian counterparts. Consequently, there is a lower level of trust with physicians, nurses, and the entire care regimen. Many women who are distrustful of biomedicine will decline certain prenatal tests, citing their own bodily knowledge as more trustworthy than their doctors hightech interpretations.[7] Even worse, some minority women may opt to avoid the distress and discomfort of the medical industry and refuse prenatal care entirely.[8] Understanding of Prenatal Testing: Many ethnic/racial minority mothers are referred to genetic counseling and prenatal testing centers after being declared at-risk for birth defects after initial screenings. However, few testing centers effectively communicate what occurs during the various tests, what the test is looking for, or what the various results could mean for the remainder of the pregnancy. Therefore, some mothers are quite uncomfortable with this lack of clearly communicated information and are consequently hesitant to pursue prenatal testing and counseling that health professionals would consider recommendable. [9]

Prenatal care (also known as antenatal care) refers to the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to appropriate specialists, hospitals, etc. if necessary. The availability of routine prenatal care has played a part in reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable infant problems. Animal studies indicate that mothers' (and possibly fathers') diet, vitamin intake, and glucose levels prior to ovulation and conception have long-term effects on fetal growth and adolescent and adult disease.[1] While availability of prenatal care has considerable personal health and social benefits, socioeconomic problems prevent its universal adoption in many developed as well as developing nations. One prenatal practice is for the expecting mother to consume vitamins with at least 400 mcg of folic acid to help prevent neural tube defects. Prenatal care generally consists of:
y y y y

monthly visits during the first two trimesters (from week 128) biweekly from 28 to week 36 of pregnancy weekly after week 36 (delivery at week 3840) Assessment of parental needs and family dynamic

Contents [hide]
y y y

y y

1 Physical examination 2 Ultrasound 3 Prenatal Care and Race in the USA o 3.1 Consequences of Minorities Limited Access to Prenatal Care o 3.2 Prenatal Care and the Latina Paradox o 3.3 Prenatal Care Improvements for Minorities 4 References 5 External Links

[edit] Physical examination Physical examinations generally consist of:

y y y y y y y

Collection of (mother's) medical history Checking (mother's) blood pressure (Mother's) height and weight Pelvic exam Doppler fetal heart rate monitoring (Mother's) blood and urine tests Discussion with caregiver

[edit] Ultrasound Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:

y y y y y y y y

Diagnose pregnancy (uncommon) Check for multiple fetuses Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition) Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists) Determine if an intrauterine growth retardation condition exists Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones) Check the amniotic fluid and umbilical cord for possible problems Determine due date (based on measurements and relative developmental progress)

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:
y y y y

7 weeks confirm pregnancy, ensure that it's neither molar or ectopic, determine due date 1314 weeks (some areas) evaluate the possibility of Down Syndrome 1820 weeks see the expanded list above 34 weeks (some areas) evaluate size, verify placental position

[edit] Prenatal Care and Race in the USA Many health professionals consider prenatal care a nearly essential practice for pregnant women; however, there are wide gaps in the American population regarding who has access to these services and who actually utilizes these services. For example, African-American expectant mothers are 2.8 times as likely as non-Hispanic white mothers to begin their prenatal care in the third trimester, or to receive no prenatal care during the entirety of the pregnancy.[2] Similarly, Hispanic expectant mothers are 2.5 times as likely as non-Hispanic white mothers to begin their prenatal care in the third trimester, or to receive no prenatal care at all.[3] The following factors impact a womans likelihood of acquiring prenatal care:
y

Health Insurance: 13% of women who become pregnant every year in the United States are uninsured, resulting in severely limited access to prenatal care. According to Childrens Defense Funds website, Almost one in every four pregnant Black women and more than one in three pregnant Latina women is uninsured, compared with one in nearly seven pregnant White women. Without coverage, Black and Latina mothers are less likely to access or afford prenatal care.[4] Currently, pregnancy is considered a pre-existing condition, making it much harder for uninsured pregnant women to actually be able to afford private health insurance.[5] Formal Education: Oftentimes, Black and Hispanic pregnant women have fewer years of formal education, which sparks a large domino effect of consequences related to prenatal care. A lack of formal education results in less knowledge about pregnancy appropriate prenatal healthcare as a whole, fewer job opportunities, and a lower level of income throughout their adult life.[6] Trust & Comfort with Healthcare Industry: Many minority women have limited experience with the healthcare industry on a whole, as compared to their Caucasian counterparts. Consequently, there is a lower level of trust with physicians, nurses, and the entire care regimen. Many women who are distrustful of biomedicine will decline certain prenatal tests, citing their own bodily knowledge as more trustworthy than their doctors hightech interpretations.[7] Even worse, some minority women may opt to avoid the distress and discomfort of the medical industry and refuse prenatal care entirely.[8] Understanding of Prenatal Testing: Many ethnic/racial minority mothers are referred to genetic counseling and prenatal testing centers after being declared at-risk for birth defects after initial screenings. However, few testing centers effectively communicate what occurs during the various tests, what the test is looking for, or what the various results could mean for the remainder of the pregnancy. Therefore, some mothers are quite uncomfortable with this lack of clearly communicated information and are consequently hesitant to pursue prenatal testing and counseling that health professionals would consider recommendable. [9]