LEC 1: Assessment of the Pregnant Client

Question 1

Subjective Data: Health Hisotry

Answer 1

• Menstural history
• Gynecological hisotry
• Obstetrical history
• Current pregnancy
• Medical history

Question 2

Health Hisotry Questions

Answer 2

• Family history
• Social history
• Review of systems
• Nutritional history
• Environment and hazards

Question 3

What are presumptive changes?

Answer 3

• Subjective
• Symptoms experienced by the woman suggestive of pregnancy
• Can be caused by conditions other than preganncy such as:
  
  • Urine tumours, polyps, infection, and pelvic congestion can cause elevated hCG levels, thus shape, size, and consistency
  • Ovarian cancer, choriocarcinoma, hydatidiform mole can elevate hCG levels, thus pregnancy test are not 100% accurate

Question 4

What are presumptive (time of occurance) sings?

Answer 4

• Fatigue (12 weeks)
• Breat tenderness (3 to 4 weeks)
• Nausea and vomiting (4 to 14 weeks)
• Amenorrhea (4 weeks)
• Urinary frequency (6 to 12 weeks)
• Hyperpigmentation of the skin (16 weeks)
• Fetal movment (quickening; 16 to 20 weeks)
• Uterine enlargment (7 to 12 weeks)
• Breast enlargment (6 weeks)

Question 5

What are positive changes?

Answer 5

• Signs that are completely objective adn caused only by pregnancy
• Nomrally after 2 weeks after a missed period, enough subjective symptoms are present to determine pregnancy
• Pregnancy can be confirmed by identifying that fetus is growing in the uterus (positive sign)
  
  • Ultrasound, palpating for fetal movements, and hearing fetal heartbeat

Question 6

What are positive (time of occurrence) signs?

Answer 6

• Ultrasound verification of embryo or fetus (4 to 6 weeks)
• Fetal movement felt by experienced clinican (20 weeks)
• Auscultation of fetal heart tones via doppler (10 to 12 weeks)

Question 7

What are probable changes?

Answer 7

• Objective
• Signs perceived by examiner
• Could be caused by conditions other than pregnancy

Question 8

What are probable (time of occurrence) signs?

Answer 8

• Braxton hicks contractions (16 to 28 weeks)
• Positive pregnancy tests (4 to 12 weeks)
• Abdominal enlargment (14 weeks)
• Ballottement (16 to 28 weeks)
• Goodell’s sign (5 weeks)
• Chadwick’s sign (6 to 8 weeks)
• Hegar’s sign (6 to 12 weeks)

Question 9

What is Naegele’s Rule?

Answer 9

• Used to determine the “due date”/ expected date of delivery (EDD)
  
  • 1st day of last menstral period (LMP)
  • Add 1 year
  • Substract 3 months
  • Add 7 days

Question 10

What is included in the obstetrical history?

Answer 10

• G: Gravida
  
  • Total number of pregnancies of any gestation- no matter how long.
  • Includes abortions, ectopic pregnancies, preterm, and full term pregnancies
• P: Para
  
  • Total number of pregnancies/ births of viable age
  • Carreid >20 weeks gestation
• T: Term
  
  • Number of term births >37 wekks (carried full term)
• P: Preterm
  
  • Number of preterm births >20 weeks and up before 37 weeks
• A: Abortus
  
  • Number of births <20 weeks
  • Induced or spontaneous abortions
• L: Living
  
  • Number of living children
  • NOT live births
• Twins count as one pregnancy/ birth but 2 infants

Question 11

When is pre-conception?

Answer 11

• 12 weeks before

Question 12

What is the duration of the 1st trimester?

Answer 12

• 0 week to 13 weeks

Question 13

What is the duration of the 2nd trimester?

Answer 13

• 14 weeks to 27 weeks

Question 14

What is the duration of the 3rd trimester?

Answer 14

• 28 weeks to 40 weels
• • or - 2 weeks

Question 15

When is post-partum?

Answer 15

• After delivery
• Up to 6 weeks

Question 16

Maternal Adaptations to Pregnancy

Answer 16

• Lab values and physical findings considered normal in non-pregnant state may not be normal for pregnant state, or vice versa
• Secondary mechanical changes exerted by growing fetus and enlarging uterus
• Change sin pregnancy affect all systems

Question 17

Changes in the Body System: GI System

Answer 17

• Mouth and Pharynx
  
  • Gums become hyperemic, swollen, and friable and tend to bleed easily
  • Saliva production increases
  • Changes in taste and smell
• Esophagus
  
  • ​Decreased lower esophageal sphincter pressure and tine, which increases the risk of developing heartburn
• Stomach
  
  • ​Decreased tone and mobility which delayed gastric emptying time, which increases the risk of gastro-esophageal reflux and vomiting
    
    • ​Morning sickness
  • Decreased gastric acidity and histamine output, which improves symptoms of peptic ulcer disease.
• Intestines
  
  • ​Decreased intestinal tone motility with increased transit time, which increases risk of constipation and flatulence
    
    • ​Decreased muscle tone related to progesterone and peristalsis leads to constipation/ delayed stomak emptying

Question 18

Changes in the Body System: Cardiovascualr System

Answer 18

• Blood Volume
  
  • ​Marked increase in plasma (50%) and RBCs (25% to 33%) compared with non-pregnant values
  • Causes hemodilution, which is reflected in a lower hematocrit and hemoglobin
  • Increas in WBCs in 2nd and 3rd trimester
• Cardiac Output (CO) and Hear Rate
  
  • ​CO increases from 30% to 50% over the non-pregnant rate by the 32nd week of pregnancy
  • The increas ein CO is associated with an increase in venous return and grater right ventricular output, especially in the left lateral position
  • Heart rate increases by 10-15 beats/min between 14 and 20 weeks of gestation, and this increase persits to term
• Blood Pressure
  
  • ​Diastolic pressure decreases typically 10-15 mmHg to reach its lowest point by mid-pregnancy
• Blood Components
  
  • ​The number of RBCs increases throughout pregnancy to a level 25% to 33%
• Finbrin and plasma fibrinogen levels increase, along with various blood-clotting factors. These factors make pregnancy a hypercoagulable state
  
  • Increase in blood clots

Question 19

Vena Caval Sydrome

Answer 19

• Supine hypotension
• Decreased venous return due to venal caval compression in the supine position leads to supine hypotension and bradycardia
  
  • ​10% of pregnancies
• Symptoms mimic that of hypovolemic shock
• Reduced blood flow to placenta causes fetal hypoxia and distress
• Avoid supone positioning- Left lateral is optimal

Question 20

Changes in the Body System: Respiratory System

Answer 20

• Enlargment of the uterus shofts the diaphragm up to 4cm above its usual position
• As muscles and cartilage in teh toracic region relax, the chest broadens, with conversion from abdominal breathing to thoracic breathing
• This leads to a 50% increase in aire volume per minute
• Tidal volume, or the volume of air inhaled, increases gradually by 30% to 40% as the preganacy progresses
• Increased oxygen by 15 to 20%

Question 21

Changes in the Body System: Renal/ Urinary System

Answer 21

• The renal pelvis becomes dialted
• The ureters elongate, widen, and become more curved above the pelvic rim
• Bladder tone decreases and bladder capacity doubles by term
• GFR increases 40% to 60% during pregnancy
• Blood flow ot the kidneys increases by 50% to 80% as a result of the increase in cardiac output

Question 22

Changes in the Body System: Musculoskeletal System

Answer 22

• Distention of the badomen with griwth of the fetus tilts the pelvis forward, shifting the center of gravity
• The woman compensates by developing an increased curvature (lordosis) of the spine
• Relacation and increased mobility of joints occur because of the hormones progesterone and relaxin, which lead to the characterisits “waddle gait”

Question 23

Changes in the Body System: Integumentary System

Answer 23

• Hyperpigmentation of the skin occurs in the areola, genital skin, axilla, inner aspects of the thightsm abd kunea nigra
• Striae gravidarum (stretch markes), are irregluar reddish streaks that may appear on the badomen, breasts, and buttocks
• The skin in the middle of the abdomen may develop a pigmented line called linea nigram wich extends from the ambilicus to the pubic areas
• Melasma occurs in 45% to 70% of pregnant women. It is characterized by irregular, blotchy areas of pirgmentation on the face (cheeck, chin, and nose)

Question 24

Changes in the System: Endocrine System

Answer 24

• Controls the integrity and duration of gestation by maintaining the corpus luteum vie hCG secretion
• Increased BMR
• Increased progesterone maintians pregnancy (relaxes smooth muscle)
• Increased estrogen enlarges uterus, breast, gentials
• Increased ocytocin at term leads to contractions, let-down relfect for lactation
• Change sin glucose regulation

Question 25

Changes in the Body System: Immune System

Answer 25

• A general enhancement of innate immunity and suppres- sion of adaptive immunity takes place during pregnancy
• These immunologic alterations help prevent the mother’s immune system from rejecting the fetus (foreign body), increase her risk of developing certain infections, and in uence the course of chronic disorders such as autoimmune diseases

Question 26

Changes in the Body System: Psychosocial

Answer 26

• Acceptance of pregnancy
• Identification with a motherhood role
• Relationship with her mother an dpartner
• Preparation for labour
• Prenantal fears of loss of control
• Self-esteem

Question 27

Changes in Vital Signs

Answer 27

• Temperature
  
  • May be slightly elevated over pre-pregnancy
• Pulse
  
  • May increase 10 to 15bpm to facilitate increase CO
• Respirations
  
  • Ranges from no change to slight increase (tidal volume)
• Blood Pressure
  
  • Decline 5 to 10mmHg until mid-pregnancy, return to normal by term

Question 28

Frequency of Prenatal Visits

Answer 28

• Q4 to 6 weeks at beginning of pregnancy until around 30 weeks
• Q 2 to 3 weeks from 30 to 36 weeks
• Q 1 to 2 weeks after around 26 weeks
• More frequent visits may be needed depending on risk facors

Question 29

Assessment on the First Prenatal Visit

Answer 29

• Initial visits after confirming pregnancy (12 weeks)
  
  • LMP, EDC< ultrasound if not sure
  • Obtain obstetircal history (TPALG)
  • Obtain relevant medical, social, psychoogical, Rx and family history
  • Complete physical exam, vital signs (BP*), baseline weight, height (BMI), pelvic exam, PAP if needed
  • Health teaching
  • Counseling: drug, alcohol or smoking use

Question 30

Assessment During Prenatal Visits

Answer 30

• Assessments at each visits include:
  
  • Blood pressure
  • Uterin size (sumphysis-fundal height)
  • Checkig urin for protein, glucose, bacteria
  • Fetal heart rate
  • Weight
  • Health teaching appropirate to gestational age
• Later visits may include vaginal exam (36+ weeks)

Question 31

Assessment of Uterine Size

Answer 31

• Symphysis Fundal Height (SFH)
  
  • ​Measure from top of uterine fundus to sumphysis pubis
  • After 20 weeks fetus has fundal height of 20cm, normal growth 1cm/week until 36 weeks
• Ultrasound gold standard for determining fetal growth

Question 32

Auscultation of the Fetal Heart Rate

Answer 32

• Doppler by 10-12 weeks
• Fetoscope by 19 to 20 weeks
• Normal Rate:
  
  • 110-160 beats/ minute
• Leopold’s maneuvers
  
  • Immediately prior to ID fetal back
• Upon initial auscultation
  
  • Maternal Pluse: important because we do not want to confuse it with the fetal heart
  • Uterine Activity: When the uterus is contracting will impact the baby

Question 33

What is the purpose for Leopold’s Maneuvers?

Answer 33

To determin fetal presentation, position, and lie

Question 34

Performing Leopld’s Manoeuvers

Answer 34

1. Place the woman in the supine positon and stand beside her
2. Perform the first manoeuvre to determine presentation
   
   • Facing the woman’s head, place both hands on the abdomen to determine fetal positon in the uterine fundus
   • Feel for the buttocks which will feel soft and irrefular (indicates vertex presentation); feel for the ehad, which will feel hard, smooth, and round (indicates a breech presentation)
3. Complete the second manoeuver to determine position
   
   • While still facing the woman, move hands down the lateral sides of the abdomen to palpate on which side the back is located (feels hard and smooth)
   • Continue to palpate to detemine on which side the limbs are located (irregluar nodules with kicking and movement)
4. Perform the third manoeuver to confirm presentation
   
   • Move hands down the sides of the abdomen to grasp the lower uterine segment and palpate the area just above the symphysis pubis
   • Place thimb and fingers of one hand apart and grasp the presentating part by brining fingers together
   • Feel for the presenting part. if the presenting part is the head, it will be round, firm, and ballottable, if it is the buttocks, it will feel soft and irregular
5. Perform the gourth manoeuver to determine attitude
   
   • Turn to face the client’s feet and use the tips of the first three fingers of each ahnd to palpate the abdomne
   • Movve fingers forward each other while applying downward pressure in the direction of the symphysis pubis. If you palapte a hard area on the side opposite the fetal back, the fetus in flexion, because you gave palpated the chin. If the hand area is on the same side as the back, the fetus is in extension, because the area palpated is the occiput.

• Also, note how your hads move. If the handsmove together easily, the fetal head is not descended into the woman’s pelvic inlet. If the hands do not move togehter and stop because of resistance, the fetal heads is engaged into the woman’s pelvic inlet