Antepartum Nursing Assessment Notes

Chapter 14 Antepartum Nursing Assessment Antepartum- time between conception and onset of labor – during pregnancy (often used interchangeable with “prenatal” care Goals of Prenatal Healthcare  *Ideally healthcare begins before conception.  Prenatal visits should begin around 8 weeks or as soon as a woman suspects she is pregnant if beyond 8 weeks.  Ensure a safe birth for mother and baby by promoting good health habits and reducing risk factors  Teach health habits that may be continued after pregnancy  Educate in self-care for pregnancy  Provide physical care o Educate that bleeding and cramping are always reason for concern during pregnancy  Prepare patients for the responsibilities of parenthood Initial Prenatal Visit (See Assessment Guide pp. 250-255)  Prenatal History o New OB Intake (NOB) o Assessment of current AND past pregnancies o Gynecologic history o Current and past medical history  Immunization history  AVOID Live vaccines: MMR, Varicella, Rubella during pregnancy! o Family medical history o Religious, cultural, and occupational history/environmental hazards o Partner history  Comprehensive health and risk assessment  Complete physical and pelvic exam  Determine EDD (estimated delivery date)  Nutrition assessment including 24 hr diet recall o Should only be adding about 300 calories a day  Psychosocial assessment: o History of emotional or physical abuse o History of emotional problems: o Depression and anxiety in general o Postpartum depression o Support systems o Overuse or underuse of healthcare system o Acceptance of pregnancy, intended or unintended o Personal preferences about the birth o Plans for care of child following birth o Feeding preference for the baby  Factors Related to Father’s Health o Family history of genetic conditions o Age o Significant health problems o Previous or present alcohol intake o Drug and tobacco use   o Blood type and Rh factor o Factors Related to o Occupation o Educational level o Methods by which he learns best o Attitude toward the pregnancy Assessment for Intimate Partner Violence Lab/Diagnostic Studies: o Pap Smear o Urinalysis  Urine culture and sensitivity o Ultrasound-depending on gestation o CBC o Blood Type and Rh Factor (Rh- moms should be treated) o RBC Antibody Screening o Rubella Titer o PPD- Tuberculosis o STIs:  HIV Screen  RPR, VDRL (syphilis serology *can be positive if patient has Crohn’s or Celiac when pregnant, then need to use different test)  Gonorrhea and Chlamydia cultures  Hepatitis B surface antigen o Genetic screening based on family history, racial/ethnic background  Ex. cystic fibrosis is recessive, test for trisomies, etc. Determining Due Dates Forty weeks considered gestational period for women (plus/minus 2 weeks) 1. Calculation from first day of LMP (last menstrual period)  Estimated date of delivery (EDD), Estimated date of birth (EDB), Due date, EDC o EDD is what we use, but these all mean the same thing  Nagele’s Rule: -3 month, +7 days from LMP and make sure year is correct o First day of period LMP: 1/10/2017 o Minus 3 months for month due: January – 3 months = October, 2016 o Plus 7 days for day due: 10+7 =17 (at end of month, start back at 1, don't add a month) o EDC = 10/17/2017  Examples: o December 15= September 22 o March 31= January 7 o November 12= August 19 o June 8= March 15  An EDB wheel can be used to calculate the due date. To use it, place the arrow labeled “first day of last period” on the date of the woman’s LMP. Then read the EDB at the arrow labeled 40. In this case, the LMP is September 8th and the EDB is June 17th. 2. An early ultrasound (U/S) to measure if LMP is unknown or unsure Uterus Measurements  McDonald’s Rule-the fundus to symphysis distance in centimeters is equal to the week of gestation between the 20th to 31st week of pregnancy  Example – a woman is 24 weeks gestation, her fundal height should measure approximately 24 cm.  At 20-22 weeks should be at umbilicus Routine assessments each visit:  Chart Review  Interval history  Focused Assessment o VS o Urine dipstick for glucose, albumin, ketones o Weight o Fundal height o FHR (typically after 12 weeks) o Fetal movement o Leopold maneuver o Edema  Pelvic or sterile vaginal exam if needed  Management of discomforts  Nutrition follow up  Nutritional Status  All pregnant mothers should consume 4mg Folic acid/Folate per day o If history of spinal cord problems, increase to 400mg/day  Weight management  Some fish restrictions  Review of risk factors Pregnancy Is Divided Into Trimesters  Each trimester is about 13 weeks: o First Trimester: to end of 12th week o Second Trimester: to end of 28th week o Third Trimester: to delivery  Predictable changes occur in the woman and the fetus  Guide prenatal care Schedule of prenatal visits:  Conception to 28 weeks (first two trimesters) – every 4 weeks  29-36 weeks – every 2-3 weeks  37 weeks to birth (term)- every week Additional Screening Assessments (See High Risk Factors Table 13-1) First Trimester Second Trimester  Triple or quad screen  Ultrasound  1 hour glucose tolerance test (GTT) at 24-28 weeks  3 hour GTT is 1 hour is positive  Hemoglobin and hematocrit  Antibody screen  Administration of RhoGHAM if mom is Rh negative with negative antibody screen Third Trimester  Group B Streptococcus screening at 35-37 weeks  H & H for baseline  Ultrasound if needed to check amniotic index and growth Torch infection is any infection that can pass from mother to fetus  Toxoplasmosis  Polio  Herpes  Cytomegalovirus  Rubella Danger Signs during Pregnancy Patients should immediately report the following:  Vaginal bleeding  Gush of fluid from vagina  Abdominal pain  Fever and chills  Dizziness, blurred vision, spots before eyes (sign of preeclampsia)  Persistent vomiting Pregnancy and Birth History Preterm: >20 <37 weeks Term: 37-40 weeks Postdate: a pregnancy that goes beyond 40 weeks Postterm: a pregnancy that goes beyond 42 weeks Gravidity and Parity Gravidity: pregnancy  Gravida: a pregnant women  Nulligravida: a women who has never been pregnant  Primigravida: a women who is pregnant for the first time  Multigravida: a women who has completed two or more pregnancies  Granmultigravida: a woman who has completed 5+ pregnancies Parity: the number of pregnancies in which the fetus has reached viability (20 weeks), whether alive or still born. (Does not include # of fetuses born, to twins are still 1)  Nullipara: a women who has not completed a pregnancy to the stage of fetal viability  Primipara: a women who has completed one pregnancy with a fetus (fetuses) who has reached stage of fetal viability  Multipara: a woman who has completed two or more pregnancies to 20 weeks of gestation or more  Viability: capacity to live outside the uterus ( defined as 20 weeks) GP:  Gravidy- total pregnancies  Parity- total births over 20 weeks (this doesn’t give the whole picture) GTPAL(M): G—the number of pregnancies including current pregnancy T—the number of pregnancies that were delivered at 37 weeks or later P—the number of pregnancies that were delivered between 20 and 37 weeks A—the number of pregnancies ending in spontaneous or therapeutic abortion BEFORE 20 weeks L—the number of currently living children M—the number of multiples (0 is none, 1 is any multiple) Examples:  Alice is pregnant. Her first pregnancy resulted in a stillbirth at 36 weeks of gestation and her second pregnancy resulted in the birth of her daughter at 42 weeks. What is her GTPAL? 31101  Constance is experiencing her fourth pregnancy. Her first ended in a miscarriage at 12 weeks, the second resulted in the live birth of twin boys at 32 weeks and the third resulted in the live birth of a daughter at 39 weeks. What is her GTPAL? 411131  Woman who has 3 kids, first one born at 36 weeks, a stillborn at 28 weeks, another child at 40 weeks and one at 32 weeks. What is her GTPAL? 42203  Your patient has a child born at 38 weeks and is currently pregnant. What is her GTPAL? 210010  Woman with 2 kids: first child was born at 38 weeks and subsequently died at 6 months old of SIDS, then twins born at 34 weeks. What is her GTPAL? 311021  Woman with 3 kids: first one born at 38 weeks, one born at 39 weeks, abortion at 6 weeks, third baby born at 40 weeks. What is her GTPALM/GP? 430130/ G4P3  Woman with no living children: 2 therapeutic abortions before 12 weeks gestation, stillborn at 24 weeks. What is her GTPAL? 20110  Woman with 4 children, first set of twins at 34 weeks, second set of twins at 38 weeks, miscarriage at 18 weeks