Nursing

Assessment of
the
Childbearing
Patient
Molly Gleason RN, BSN
N510 Advanced Health Assessment
Methodist College
Did you sign in?
● Monday, September 11, 2017
● 1500-1600
● Course: N372 (OB)
● Conference Room 1/Sim Room 1
 Welcome!

● Molly Gleason RN, BSN

● Labor & Delivery Nurse at Methodist Hospital
● Former Clinical Skills Educator at Methodist
College
● Future Nurse Educator
Learning Objectives
First we will review the information, and then practice hands on in the Simulation Room!

Purpose: To educate BSN level students on the health assessment of a childbearing patient in order
to provide acute, efficient care

Goal: The students will understand required assessment components of the childbearing patient and
be able to perform these assessments proficiently in the clinical setting

At the end of this lesson, the students will be able to . . .

● Discuss the physiologic and anatomic changes at term pregnancy

● Collect objective and subjective data of the childbearing patient
● Apply the information collected to select pertinent nursing diagnoses
Supplies
● Your patient (Manikin: Noelle)
● Stethoscope
● Blood pressure cuff
● Reflex hammer
● Tape measure
● Light
● Sterile gloves
● Lubricant
● IV with a double lumen j-loop
● LR on blood tubing
● LR on primary tubing on a pump
 Basic Pathophysiologic
Changes during Pregnancy
Basic Pregnancy Changes
● Skin, Hair, & Nails
○ Striae gravidarum (stretch marks)
○ Hyperpigmentation
■ Linea nigra
■ Chloasma
■ Areola
■ Perineum
○ Spider nevi (angioma)
○ Palmar erythema
○ PUPPP (pruritic urticarial papules)
○ Acne vulgaris
○ Hirsutism (hair growth)
○ Nail growth
● (Weber & Kelley, 2014).
Basic Pregnancy Changes
● Ears & Hearing
○ Decrease in hearing
○ Ear fullness/pain
● Mouth, Nose, Throat, & Sinus
○ Gingival bleeding
○ Epulis (gum granuloma)
○ Vocal change
○ Nasal congestion
○ Epistaxis (nosebleed)
● Thorax & Lungs
○ Increased AP diameter
○ Shortness of breath
● (Weber & Kelley, 2014).
Basic Pregnancy Changes
● Breasts
○ Tingling
○ Tenderness
○ Enlargement
○ Montgomery tubercles
○ Superficial veins
○ Striae
○ Hyperpigmentation
○ Colostrum expression
● Heart
○ Increase in HR
● (Weber & Kelley, 2014).
Basic Pregnancy Changes
● Peripheral Vascular System
○ Anemia
■ Blood volume increases by 20-30%, which increases the supply of iron and vitamins that the body needs to
make hemoglobin (American Society of Hematology, 2017).
○ Dizziness
○ Lightheaded
○ Edema
○ Varicosities
○ Thrombophlebitis
● Abdomen
○ Diastasis recti abdominis
○ Lower pelvic ligament stretching and discomfort
● (Weber & Kelley, 2014).
Basic Pregnancy Changes
● GI & GU Systems
○ Urinary frequency
○ Kidney infection
○ Constipation
○ Hemorrhoids
○ Heartburn
○ Gallstones
○ Ptyalism (extra salivation)
○ Pica
● Genitalia
○ Fundal height
○ Goodell’s Sign
■ Cervical softening
○ Chadwick’s Sign
■ Blue discoloration
○ Vaginal discharge
● (Weber & Kelley, 2014).
Basic Pregnancy Changes
● Musculoskeletal System
○ Lordosis
○ Shoulder droop
○ Flexible joints
○ Gait changes
○ Lean back with change in center of gravity
○ Backaches
○ Increase in shoe width
○ Increase in pelvic outlet diameter
● Neurologic System
○ Thigh tingling
○ Carpal Tunnel
○ Leg cramps
○ Dizziness/lightheadedness
○ Supine hypotensive syndrome
● (Weber & Kelley, 2014).
Health Assessment
Subjective Data Collection
● Biographical Data ○ Pregnancy history (Gravida-Para)*
○ Name, DOB, address, phone number ○ Pregnancy complications
○ Educational level, occupation, work status ○ Fertility issues
● Health History ○ STD history
○ Pregnancy weight gain* ○ Vaginal infection history
○ Date of last menstrual period ○ Major medical problems
■ Diabetes
○ History of viral illness
■ Hypertension
○ Symptoms of nausea or vomiting
○ Allergies (medication, foods, or latex)
○ Bowel habits
○ Current medications
○ Urinary symptoms
○ Immunizations
○ Appetite
○ History of birth defects
○ Sleep
○ Family history
○ Mood
○ Drugs/Alcohol/Cigarettes
○ Exercise
○ Chemical exposure
○ Pain
○ FOB involvement
○ Feeding choices for infant
○ (Weber & Kelley, 2014).
○ Support system
Pregnancy Weight Gain
Underweight: 28-40 pounds

Normal Weight: 23-35 pounds

Overweight: 13-25 pounds

Twin Gestation: 35-45 pounds

● Where does the weight come from?

○ Breasts: 1.5-3 pounds
○ Uterus: 2.5 pounds
○ Fetus: 7-7.5 pounds
○ Placenta: 1-1.5 pounds
○ Amniotic Fluid: 2 pounds
○ Extravascular Fluid: 3.5-5 pounds
○ Maternal Reserves: 4-9.5 pounds
● (Weber & Kelley, 2014).
Gravida-Para
● Gravida
○ Total number of pregnancies
○ Term = 38-42 weeks
○ Preterm = 20-38 weeks
● Para
○ Number of pregnancies delivered at 20 weeks or greater gestation
● Abortion
○ Termination of pregnancy
■ Spontaneous = miscarriage
■ Elective/Induced = induced prior to the 20th week of gestation
● Living
○ Number of living children
● Will also include term and preterm
● (Weber & Kelley, 2014).
Let’s Practice!
● A patient presents to the L&D unit with complaints of contractions every 2-5
minutes lasting 40-60 seconds long. She is 40/3 weeks. She has a 1 year old son
at home and this is her second pregnancy. What are her G’s and P’s?
○ G2P1
● A patient presents to the L&D unit with complaints of vaginal discharge. She is
31/1 weeks. She has two children at home and a history of a miscarriage at 12
weeks. What are her G’s and P’s?
○ G4P2
○ What will this patient’s G’s and P’s be after delivery?
■ G4P3
● A patient presents to the postpartum unit after twins the evening prior via
c/section. This was her first pregnancy. What are her G’s and P’s?
○ G1P2
Objective Data Collection
● Vital signs*
○ Peripheral vascular system
● Weight
○ DTRs and clonus
● Lab results*
○ Abdomen
● Behavior and mood
■ Fundal height*
● Skin, hair, and nails
■ Leopold’s Maneuvers*
● Head and neck
■ Contraction pattern*
● Eyes
■ Fetal heart rate*
● Ears
■ Fetal movement*
● Mouth, throat, nose
■ AFI (Amniotic Fluid Index)
● Thorax and lungs
○ Genitalia
● Breasts
■ Cervical Exam*
● Heart ● (Weber & Kelley, 2014).
Vital Sign Changes during Pregnancy
● Blood Pressure
○ Normal: 90-120/60-80
○ Second Trimester Changes: BP decreases due to the relaxation of the blood vessels, rises to
baseline between 32-34 weeks
○ Elevation of BP after 20 weeks indicates pregnancy-induced hypertension or preeclampsia
○ Decrease in BP after 20 weeks can indicate supine hypotension syndrome
● Pulse
○ Normal: 60-100
○ Pulse can increase 10-15 bmp during pregnancy
● Temperature
○ Normal: 97-99 F
○ Elevation of temperature can indicate infection
● Respirations
○ Normal: 12-20 per minute
○ No change in pregnancy
● (Weber & Kelley, 2014).
Lab Results
● OB Panel
○ Blood type*
○ Rh factor*
○ Rubella
○ HIV antibodies
○ Hepatitis B
○ RPR
● Pap Smear
● UA (for UTI)
● Vaginitis Panel
● STD Screen
● Drug Screen
● ROM+
● PIH Labs
○ CBC, CMP, LDH, Uric Acid, UA (looking at protein)
Blood Type & Rh Factor
● Blood Type: O, A, B, or AB
● Rh Factor
○ An inherited protein on the surface of red blood cells
○ If the patient has Rh factor, they are Rh positive (most common)
○ If the patient does not have Rh factor, they are Rh negative
● Rh Incompatibility
○ If the patient is Rh negative and the fetus is Rh positive
○ The Rh antibodies destroy fetal red blood cells, causing hemolytic anemia, oxygen deprivation,
or death to the fetus
● Treatment
○ Rh immunoglobulin (RhIg) made from donated blood
○ Prevents the production of Rh antibodies (sensitization) to prevent fetal hemolytic anemia
○ Given at week 28 of pregnancy to prevent Rh sensitization
○ Given again within 72 hours after the delivery of an Rh-positive infant
● (ACOG, 2013).
Let’s Practice!
● Which of the following patients needs a RHOGAM injection?
○ A patient who is AB+ who had a miscarriage at 7 weeks
○ A patient who is B- who delivered via c/section at 33 weeks
○ A patient who is O+ who delivered vaginally at 41 weeks
○ A patient who is A+ who had twins at 35 weeks
● The patient who is B- will need the injection!
Fundal Height
● The uterus can weigh up to 1,000 g
● Can hold up to 5 L of amniotic fluid
● Fundal height is the distance from the pubic bone to the top of the uterus
measured in centimeters (Tobah, 2017).
● Fundus
○ 10-12 Weeks: At the top of the symphysis pubis
○ 16 Weeks: Halfway between the symphysis pubis and the umbilicus
○ 20 Weeks: At the umbilicus, then 1 cm per week until term
○ 40 Weeks: At the xiphoid process or below
■ In the last few weeks, the measurement may drop due to lightening
● Engagement and descent of the fetal head in the pelvis
● McDonald’s Rule
○ After 20 Weeks: Grows 1 cm per week, and should correlate to the number of weeks gestation
■ Example: If the patient is 30 weeks pregnant, her fundal height should be 30 cm
● (Weber & Kelley, 2014).
Leopold’s Maneuvers

A: Palpate the fundus to establish which end of the fetus is in the upper part of the uterus. If either the head or breech of the fetus are in the fundus then
the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.

B: Firm pressure is applied to the sides of the abdomen to establish the location of the spine and extremities.

C. Using the thumb and fingers of one hand the lower abdomen is grasped just above the pubic symphysis to establish if the presenting part is engaged. If
not engaged a movable body part will be felt. The presenting part is the part of the fetus that is felt to be in closest proximity to the birth canal.

D. Facing the maternal feet the tips of the fingers of each hand are used to apply deep pressure in the direction of the axis of the pelvic outlet. If the head
presents, one hand is arrested sooner than the other by the cephalic prominence while the other hand descends deeply into the pelvis. If the cephalic
prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back ,
then the head is extended and the fetus is in face presentation (Nishikawa & Sakakibara, 2013).
Contraction Pattern
● Braxton Hicks
○ Occur after 20 weeks, feels light tightening, are infrequent and irregular, can be uncomfortable
but not painful, resolve with rest, hydration, or position changes, do not get stronger, longer, or
closer together, and do not cause cervical change (Marcin, 2017).
● Preterm Labor
○ Occur before 37 weeks, can feel like pressure, cramping, or a backache, can be regular but
infrequent (Marcin, 2017).
● Early Labor (0-3 cm)
○ Duration: 30-90 seconds long
○ Frequency: 5-15 minutes apart
○ Palpation: Mild (Weber & Kelley, 2014).
● Active Labor (4-10 cm)
○ Duration: 60-90 seconds long
○ Frequency: 2-3 minutes apart
○ Palpation: Moderate to strong (Weber & Kelley, 2014).
Contraction
Patterns
TOCO Monitor vs IUPC
● TOCO
○ The most widely used method for contraction
monitoring
○ External pressure sensor, or
‘tocodynamometer’ strapped onto the
abdomen, positioned over the fundus
○ Indirectly records contractions through
sensing changes in skin tension arising from
the uterine muscular activity (Huntleigh, 2011).
● IUPC
○ Catheter in the amniotic fluid space
surrounding the fetus inside the uterus
○ A pressure sensor in the tip of the catheter
provides an accurate, absolute, measure of
pressure calibrated in mmHg (Huntleigh, 2011).
○ Measured in montevideo units (MVUs)
Adequate
Pushing
Tachysystole
Fetal Heart Rate
● Fetal movement is an indicator of fetal well-being
● Normal FHR is 110-160
● What you are looking for:
○ Baseline rate
○ Accelerations: Raised periods of FHR that reflect a normal physiological response to increased
levels of activity then return to baseline rate
○ Decelerations: Periods of reduced FHR that reflect a defensive mechanism, usually an
autonomic one, to protect the fetus during periods of transient hypoxia
■ Early: Occurs simultaneously with the contraction, gradual onset (head compression)
■ Late: Delayed, starts at the peak of the contraction and ends after the contraction is over
with a gradual onset (utero-placental insufficiency)
■ Variable: Not correlated with a contraction, abrupt onset (cord compression)
○ Variability: A measure of ‘beat to beat’ changes from one beat interval to the next
○ (Huntleigh, 2011).

● Category I, II, or III

Fetal Heart Rate
 VEAL CHOP Video
https://www.youtube.com/watch?v=L6aqT1nch8E
Accelerations
Early Decelerations
Late Decelerations
Variable Decelerations
Prolonged Deceleration
Absent Variability
Minimal Variability
Moderate Variability
Marked Variability
US Monitor vs FSE
● US
○ Ultrasound transducer placed on the outside of the abdomen
● FSE
○ Fetal scalp electrode
○ Placed on the scalp of the infant
Cervical Exam
● When the baby drops down into the
pelvis, the baby’s head puts pressure
on the cervix
● The body to releases oxytocin, which
causes contractions, which applies
more pressure to the cervix, which
causes cervical change
● Dilation = how wide the cervix is
● Effacement = how thin the cervix is
● Station = how low the head is
● Anterior vs Posterior
● (Weber & Kelley, 2014).
Cervical Exam
 Cervical Exam Video
https://www.youtube.com/watch?v=TcxHz3msKro
Document your Findings!
● Labor and Delivery is one of the most sued areas in healthcare
● OB/GYNs are the most frequently sued physicians
○ According to recent studies, ob/gyns and surgeons are most likely to be sued among all
physicians (Peckham, 2016).
Let’s Practice!
Did we meet the objectives?
Are you able to...
● Discuss the physiologic and anatomic changes at term pregnancy
● Collect objective and subjective data of the childbearing patient
● Apply the information collected to select pertinent nursing diagnoses

If not, please see me and we can continue practicing!

Please fill out
an evaluation
Thank you!
References
ACOG. (2013, September). The rh factor: How can it affect your pregnancy. The American College of Obstetricians and
Gynecologists. Retrieved from
https://www.acog.org/Patients/FAQs/The-Rh-Factor-How-It-Can-Affect-Your-Pregnancy

American Society of Hematology. (2017). Anemia and Pregnancy. Retrieved from

http://www.hematology.org/Patients/Anemia/Pregnancy.aspx

Huntleigh. (2011, April 26). An overview of fetal monitoring. Sonicaid Fetal Monitoring. Retrieved from
http://www.arjohuntleigh.net/diagnostics/Admin/files/20110615151756.pdf

Marcin, A. (2017). Types of contractions during labor. Healthline. Retrieved from

http://www.healthline.com/health/pregnancy/types-of-contractions#1

Nishikawa, M., & Sakakibara, H. (2013). Effect of nursing intervention program using abdominal palpation of Leopold’s
maneuvers on maternal-fetal attachment. Reproductive Health, 10, 12. http://doi.org/10.1186/1742-4755-10-12

Peckham, C. (2016, January 22). Medscape malpractice report 2015: why OB/GYNs get sued. Medscape. Retrieved from
http://www.medscape.com/features/slideshow/malpractice-report-2015/obgyn

Tobah, Y. (2017, March 4). Fundal height: An accurate sign of fetal growth? Mayo Clinic. Retrieved from
http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/expert-answers/fundal-height/faq-20057962

Weber, J., & Kelley, J. (2014). Health assessment in nursing. Philadelphia: Wolters Kluwer