Chapter 20: Assessment of the pregnant patient Flashcards
initial health history of a pregnant patient does not differ greatly from the health history of any other adult patient.
• The gynecologic and obstetric history include information about the last menstrual period, expected date of delivery, and the course of past pregnancies and deliveries.
Prenatal visits are recommended
every 4 weeks up to 28 weeks; every 2 weeks from 28 to
36 weeks; and weekly after 36 weeks. The initial prenatal visit
includes a comprehensive history and examination; follow-up
visits are more limited in scope, monitoring the progress of
the pregnancy and assessing for complications.
Laboratory tests used to determine pregnancy
detect an antigen-antibody
reaction between human chorionic gonadotropin (hCG)
hormone and an antiserum within the urine or blood
Many
physiologic changes are recognized as signs and symptoms of
pregnancy. Some of these findings are categorized as:
(1) presumptive symptoms (i.e., symptoms experienced by the
woman); (2) probable signs (i.e., changes observed by the
nurse); and (3) positive signs (i.e., findings that prove
the presence of a fetus).
Integumentary System
• Increased estrogen increases vascularity to the skin, causing
itching and hands and feet to take on reddened appearance.
• Increased secretion of melanotropin causes pigmentation
changes to the skin, including chloasma (mask of pregnancy);
linea nigra (dark-pigmented line on abdomen); and
increased pigmentation to nipples, areolae, axillae, and vulva.
• Increasing size of breasts and abdomen contribute to striae
gravidarum (stretch marks) over abdomen and breasts.
• Increased hair or nail growth is reported by some individuals.
Respiratory System
• Uterine enlargement pushes up on diaphragm, causing periodic
shortness of breath.
• Respiratory rate may increase slightly; tidal volume increases;
breathing becomes more thoracic than abdominal; thoracic
cage widens.
Cardiovascular System
• Blood volume increases by 1500 mL to meet the need of an
enlarged uterus and fetal tissue, causing increased cardiac
workload (increased heart rate).
• Uterine enlargement pushes up on the heart, causing it to
shift upward and forward.
• Enlarged uterus increases pelvic pressure, causing decreased
venous return, which results in varicosities and edema in
lower extremities.
Gastrointestinal System
• Rise in human chorionic gonadotropin early in pregnancy
causes nausea and vomiting (morning sickness).
• Uterine enlargement results in displacement of intestines
and decreased peristalsis, causing heartburn and constipation,
respectively • Increased pelvic pressure and vascularity cause
hemorrhoids.
• Increased estrogen increases vascularity and tissue proliferation
of gums, resulting in swollen and bleeding gums.
Urinary System
• Increased pressure of growing uterus on bladder in early
pregnancy and fetal head exerting pressure on bladder in late
pregnancy result in nocturia and urinary frequency
Musculoskeletal System
• Increased size of uterus and growing fetus results in the
center of gravity moving forward, causing lordosis (increased
spinal curvature) and back discomfort; waddling gait and
balance problems may occur.
• Abdominal wall muscles stretch and lose tone, which may
lead to separation of abdominal muscles (diastasis recti) in
the third trimester.
Reproductive System
• Uterus enlarges, and fundus becomes palpable because of
growing fetus.
• Vagina, vulva, and cervix take on bluish color caused by
increased vascularity.
Breasts
• Breasts become full and tender early in pregnancy.
• Breasts enlarge as pregnancy progresses.
• Nipples and areolae are more prominent and deeply
pigmented.
• Increased mammary vascularization causes veins to become
engorged; visible under skin surface.
Presumptive signs
Breast fullness/tenderness 3-4 Amenorrhea 4 Nausea, vomiting 4-12 Urinary frequency 6-12 Quickening (fetal movement) 16-20
Probable signs
Chadwick’s sign (violet-blue color to cervix) 6-8
Goodell’s sign (softening of cervix) 5
Hegar’s sign (softening of lower uterine segment) 6-12
Positive pregnancy test (hCG):
Serum 4-12
Urine 6-12
Ballottement 16-28
Positive signs
Visualization of fetus by ultrasound 5-6 Auscultation of fetal heart tones: Doppler 8-17 Fetoscope 17-19 Palpation of fetal movements 19-22 Observable fetal movements Late pregnancy
An obstetric history includes gravidity
The acronym GTPAL may be of help
in remembering this system of documentation
(G) (number of
pregnancies, including current pregnancy); the number of
full-term births (T); the number of preterm births (P); the
number of abortions (A) (both spontaneous “miscarriages”
and “therapeutic” pregnancy interruptions); and the number
of living children (L).
The obstetric history also includes specific data regarding
each pregnancy. Document the following information:
• The course of each pregnancy (including the duration
of gestation, date of delivery, and significant problems
or complications)
• The process of labor (including manner in which labor
was started [i.e., spontaneous or induced], length of
labor, and complications associated with labor)
• The delivery (presentation of the infant, method of
delivery [i.e., vaginal or cesarean section], and pain
management strategies used for delivery, if any)
• Condition of the infant at birth (including weight)
• Postpartum course (including any maternal or infant
problems)
ESTIMATED DATE OF BIRTH
Nägele’s Rule
Determine the first day of the last menstrual period (LMP), subtract 3 months, and then add 7 days. Example: First day of LMP =November 1 − 3 months = August 1 \+ 7 days = August 8 EDB*
pregnant woman’s family history should specifically address
the childbearing history of her mother and sister(s),
including
multiple births, chromosome abnormalities, genetic disorders,
congenital disorders, and chronic illnesses such as
diabetes mellitus or renal disease and cancer.
Compared with other known painful
events or experiences, the potential for achieving satisfactory
pain relief is high because of the uniqueness of this pain
experience. Unique points include the following:
• The woman knows that the pain will happen.
• The woman knows approximately when (within a week or
so) the pain will happen.
• The woman knows that there will be a predictable pattern
to the pain.
• The woman knows that there is a time limit to the pain
experience (hours as opposed to days or weeks) and that
it will end.
• The woman knows that there is a tangible end product
associated with the birth (i.e., the birth of her child).
Pica
ingestion of nonnutritive substances….
Clay, starch, baking soda, and dirt are some of the reported cravings
during pregnancy
smoking increases the
need for
vitamin C, a nutrient that has increased intake
requirements during pregnancy
Pulse: The heart rate
increases as much as 10 to 15 beats/min
Preexisting hypertension in pregnancy
significantly increases risk
of preterm delivery and infant mortality.
Pregnancy-induced hypertension
(PIH), also known as gestational
hypertension
It is characterized by systolic blood pressure of at least 140 mm Hg, a rise of 30 mm Hg or more above the usual level in two readings 6 hours apart, diastolic blood pressure of 90 mm Hg or more, or a rise of 15 mm Hg above baseline in two readings done 6 hours apart.
EXPECTED WEIGHT GAIN
DURING PREGNANCY
First trimester 3-5 lbs (1.6-2.3 kg)
Additional pounds
Second trimester 12-15 lbs (5.5-6.8 kg)
Third trimester 12-15 lbs (5.5-6.8 kg)
palmar erythema and is considered an expected finding.
Pinkish-red blotches or diffuse mottling of the hands caused by an increase in estrogen
is termed palmar erythema
chloasma, or the mask of pregnancy
Blotchy, brownish pigmentation of the face (i.e., chloasma, or the mask of pregnancy)
is an expected finding
these may be caused by
PIH
PIH may cause blurred vision. Chromatopsia may be noted, characterized by unusual color perception, seeing spots, or blindness in the lateral visual field. This requires immediate follow-up. Retinal arteriole constriction, disc edema, and retinal detachment
A normal
variation seen in many women toward the end of the third trimester is an epulis
An epulis is hypertrophied gum tissue that presents as a small painless raised nodule.
The heart shifts laterally in response to the positions of the uterus and diaphragm
The point of maximum impulse also shifts upward and rotates slightly to
the left. Murmurs, splitting of S1 and S2, and the presence of S3 may be heard after the
twentieth week of gestation
Following the first trimester, colostrum may be expressed from
the breast (a yellowish discharge).
breasts,,,, signs
consistent with malignancy.
Thickening of the nipple tissue, a mass, and loss of elasticity
Nipple discharge is considered an abnormal
finding (except for expression of colostrum as described).
Any discrepancy greater than 2 cm between fundal height and the estimate of gestational age (based on last menstrual period) should be evaluated further.
A uterus that is larger
than expected may be caused by inaccurate
dating of the pregnancy, more than one fetus, gestational diabetes,
or polyhydramnios (excessive fluid in
the uterus). A uterus that is smaller than expected for gestational age may
be caused by inaccurate dating of the pregnancy or growth retardation
of the fetus.
The expected fetal heart rate ranges
between 120 and 160 beats/min.
Leopold’s maneuvers
The outline of the fetus can be determined after 26 to 28 weeks
The patient should be lying supine, with
head slightly elevated and knees flexed slightly. The fetal lie, presentation, position,
and attitude can be determined through these maneuvers
