Chapter 11: Nursing Care Related to Assessment of Pregnant Family

 Prenatal care is a major strategy for helping to reduce complications of pregnancy such as
the number of preterm or low birth weight babies born each year
 Ideally, preparations for a healthy pregnancy begins during a woman's childhood

Nursing Process Overview

Assessment
 Establish baseline data relevant to a woman's health
 Identify health promotion strategies that will be important at every prenatal visit
 Obtaining detailed health and sexual history screening for the risk of teratogen
 Explain why is pacific assessment data are important has the potential to lead to health
teaching
 Nursing Diagnosis
 Usually, focus on the response of a woman and her family to that information,
includes:
a. decisional conflict related to desire to be pregnant
b. risk for ineffective coping related to confirmation of unintended pregnancy
 Appropriate to pronounce care include:
a. health-seeking behaviour related to guidelines for nutrition and activity during
pregnancy
b. deficient knowledge regarding exposure to a teratogen during pregnancy
c. health-seeking behaviour related to strong cultural desire to have a healthy
child 
d. risk for injury to fetus related to lifestyle choices 
Outcome Evaluation and Planning
 Be certain to reserve sufficient time at prenatal visits
 Establish a pattern of regular appointments
 Ask if the woman has transportation to the health care facility
Implementation
 Teaching women and their families about safe pregnancy lifestyle
 Offer a woman and her partner pamphlets that cover the same topic discussed verbally
 Be certain of printed materials you give to families are consistent with what you say
and with the views of the patient's obstetrics health care provider
Outcome Evaluation
 Couple state they have reached a mutual decision to both stop smoking
 Patient states she feels well-informed about the common body change of pregnancy
and actions to take to relieve any discomfort this cause
 Patients list ways to avoid exposure to her work site during pregnancy

A. Health Promotion and Assessment Before and During Pregnancy

Prenatal care’s purposes:
 Establish a baseline of present health
 Determine the gestational age of the fetus
 Monitor fetal  development and maternal well being
 Identify women at risk for complications
 Minimize the risk of possible complication by anticipating and preventing
problems before they  occur
 Provide education about pregnancy, lactation, and newborn care

1. The preconception visit

Is best if it is not provided  at a single visit but included at every healthcare visit
for a woman and childbearing age 
A woman should schedule a specific appointment with her primary care provider
At this time, her hemoglobin and level and blood type may be determined and, if
appropriate,  Papanicolaou or a pap smear taken
 2. Choosing a healthcare provider for pregnancy and childbirth
Once a woman becomes pregnant, her next step is to choose a primary health care
provider to care for her throughout the pregnancy of birth
(pp.229, box 11.2:  suggestions to individualize prenatal care)

3. Health assessment during the first prenatal visit

Women shoes schedule a first prenatal visit as soon as they suspect they are
pregnant
Traditionally prenatal visit schedule a still needed during a usual pregnancy, after
the first prenatal visit, return appointments are usually scheduled every four
weeks through the 28th week of pregnancy, every two weeks through the 36th
weeks, and then every week until birth
An important focus is to educate about pregnancy and help a woman achieve a
healthy pregnancy lifestyle and to assure woman in their pregnancy is progressing
well

B. The Initial Interview 

Note: pregnancy symptoms are subtle, so a woman may not regard certain information as
important, causing her to provide vague answers instead of specific information in this area.
 The interview is best in a private, quiet setting.
 Caution of woman that a first visit may be lengthy of all things that need to be
accomplished
 Be certain to ask how a patient wants you to address her taking into account gender
identification

1. Support person’s role

Invite the support person and family to join her while talking about pregnancy
symptoms if she wanted to
Provide interview time with a partner so the partner can express of his or
her concerns and worries 

2. Components of the health history (pp.231, table 11.1:  patient profile: typical day
and social history for a pregnant patient)
a) Demographic data
usually obtained including name, age, telephone number, e-mail address, religion,
ethnicity, type and place of employment, and health insurance information

b) Chief concern
The reason the woman has come to the healthcare setting
 Document the date of her last menstrual period
 Elicit information about the usual sign that occurs with early pregnancy such
as nausea vomiting breast changes or fatigue
 As if she is feeling any discomfort with her pregnancy such as constipation
backache or frequent urination
 Document whether the pregnancy was intended

c) Family Profile
It helps you get to know her, identify here important support person, shape the
nature and kind of questions you want to ask, and evaluate the possible impact of
the woman's culture on care
 Marital status and support people available
 Educational level of her and her partner
 Know exactly what her job consists
 Size and structure of the apartment of the house
 Family composition
 Lifestyle
 Document whether a woman has recently experienced any lifestyle
changes

d) History of Past Illnesses

 Need because a past condition can become active during or immediately
following pregnancy
Ask whether a woman has childhood diseases and any allergies including drug
sensitivities

e) History of Family Illnesses

Identify potential problems a woman or her infant could experience during
pregnancy or after birth

f) Day History/ Social Profile

Information about a woman's current nutrition, elimination, sleep, recreation, and
interpersonal interaction can be elicited best by asking a woman to describe what
her typical day is like

3. Gynecologic History
a) Menstrual History
Information to obtain includes your age of menarche and how well she was
prepared for it. 
Ask about her usual cycle, including the interval, duration, amount of menstrual
flow, and any discomfort she feels

b) Perineal and Breast Self- examination

Inspecting the external genitalia monthly for signs of infection or lesions
Breast self-examination is no longer thought to yelled enough reliable information
to be continued as a monthly self-care routine but woman should be alerted to
normal breast changes

c) Past Surgery
Can influence a woman’s ability to conceive and give birth

d) Reproductive Planning

e) Sexual History
Establish a woman's risk for contracting a sexually transmitted infection such as
herps or hepatitis c
Include history taking regarding patient sexual and rotation and gender identity as
there are an increasing number of patients who go more comfortable discussing
their gender

4. Obstetric History (pp. 237)

Do not assume the current pregnancy is a woman first pregnancy simply because
she is very young or says she has only recently been married.

5. Review of Systems
It completes the subjective information of health history. 
Use a systematic approach such as a head-to-toe and explain what you will be
doing by an explanation.
It also helps women recalled concerns they forgot to mention earlier, such as a
urinary tract infection, a condition that can influence the outcome of the
pregnancy and thus would be important to your history taking

6. Interview Conclusions
Ask if there is anything you have not covered that the woman want to discuss

D. Physical Examination
Ask a woman to void for a clean catch urine specimen before the examination because this
will provide a urine specimen for either immediate dipstick or laboratory testing of bacterial,
protein, glucose, and ketone determination
Note: empty bladder makes the pelvic examination more comfortable.
1. Baseline Height/Weight and Vital Measurement
Measured at a first prenatal visit to establish a pregnancy BMI to serve as a bust baseline
for future comparison
When obtaining a woman's weight, be certain to convey an air of “weight gain is healthy” 
so a woman feels comfortable gaining 30 to 40 pounds during pregnancy
Measure vital signs, including blood pressure, respiratory rate, and post rate, again , for
baseline level

2. Assessment of Body System

Begins of general appearance to form an overall impression of women's health and
wellbeing 
After the general assessment, examine the patient head to toe by beginning with the head
and the scalp and ending with extremities and skin

3. Measurement of Fundal Height and Fetal Heart Sounds

At 12 weeks of pregnancy, assess whether the fundus of the uterus is palpable, measure
the fundal height and plot the height on a graph such as the shown in figure 11.3 (pp. 242)
Auscultate for fetal heart sounds by doppler if the pregnancy is past 10 weeks
Palpate for fetal outline and position after the 28th week as a further estimation of fetal
size and growth

4. Pelvic Examination
Information on the health of both a woman's internal and external reproductive organ
Equipment required is on page 242
Have the reputation of being painful and causing a loss of modesty
May be particularly difficult if a patient has a history of sexual abuse or assault
Allow a woman the opportunity to walk with the person performing the examination while
sitting up, before being placed in lithotomy position, because this enhance self-esteem and
control.
If a woman is an uncomfortable lithotomy position, the exam can be done with her lying flat on a
bed or table with her knees raised. make sure her buttocks extends slightly beyond the end of the
examining table if possible. place a pillow under her head or slightly elevate the head of the
examination table to help her relax your abdominal muscles.  properly drape her with a draw sheet
over her abdomen that extends over her legs for modest. 
give explanations of what is happening, what she might be feeling and what the examiner doing
The conversation is not helpful and breathes in and out technique can help her relax

a) External genitalia
 Herpes simplex 2: appears as clustered, pinpoint vesicles on an
erythematous (reddened) base on vulva that feel painful when touched or
irritated.
 Skene glands that empty into urethra and Bartholin glands that enter the
posterior vagina : checked for size and consistency
b) Internal Genitalia
 Must be opened and held open with speculum
 The cervix is inspected for position and color
 Trichomoniasis: a protozoal infection that causes petechial spots on the
vaginal walls, cervical redness and a profuse, whitish, bubbly discharge
 Candidal Infection: cause an itching and burning sensation in addition to
producing a clumpy cheese-like discharge that may cause bleeding.
 Gonorrhea infection: thick, greenish-yellow discharge and extreme
inflammation.
 Carcinoma of cervix: irregular, granular growth
 Cervical polyps: red, soft, pedunculated benign protusions

c) Papanicolau Smear
Taken from the endocervix at a first prenatal visit to be certain a precancerous or
cancerous condition of the uterine cervix, vulva, or vagina is present
Bethesda system used to interpret pap smears (pp. 245, table 11.6)

d) Vaginal Inspection
 Speculum Examination:
 Trichomoniasis: microscope slide wet mount sample
 Group B streptococcus:done at 35 to 37 weeks of gestation

e) Examination of Pelvic Organs

A bimanual examination is performed to assess the position, contour, consistency
and tenderness of pelvic organ
Ovarian cysts, enlarged fallopian tubes and enlarged uterus can be found

f) Rectovaginal Examination
Index finger is reinserted into vagina and middle fingers into rectum. By palpating
the tissue between examining fingers in this way, it is possible to assess the
strength and irregularity of the posterior vaginal wall. It can be uncomfortable
because of rectal pressure.

g) The Pelvis: Establishing Adequacy for Childbirth

Pelvis - bony ring formed by 4 united bones ( 2 innominate or flaring hip bone,
coccyx and sacrum)
-serves both support and protect pelvic organs
Innominate bone divided into 3: ilium, ischium and pubis
 Ilium- forms upper and lateral portion
 Ischium- inferior portion and has 2 projection: (a) ischial tuberosities-part
of bone which person sits and use to determine width (b) ischial spines-
small projections that extend from lateral aspect of pelvic to pelvic cavity,
it mark as the midpoint of pelvis and used to assess the level to which a
fetus has descended into birth canal just before or during labor
 Symphysis pubis- where the 2 anterior portions of innominate meet
Sacrum- upper posterior portion, has sacral prominence that is used a
landmark when securing pelvic measurement
Coccyx- below sacrum, composed of 5 very small bones fused together. It
has sacrococcygeal joint.

For obstetric purposes, pelvis divide into false pelvis and true pelvis

1) False pelvis
Supports the uterus during late months of pregnancy
Aids in directing the fetus into the true pelvis of birth
Divided from the true pelvis only by an imaginary line, the linea terminalis

 Inlet- entrance of true pelvis or upper ring bone through which the
fetus must pass to be born vaginally.
 Outlet- inferior portion of the pelvis, or that portion bounded in the
back by the coccyx, on the sides by the ischial tuberosities, and in front
by the inferior aspect of the symphysis pubis
 Pelvic cavity- space between the inlet and outlet.

h) Estimating Pelvic Size

Types of Pelvises Found in Women:
a) Gynecoid or female pelvis: Has an inlet that is well rounded forward and
backward and has a wide pubic arch. This type is ideal for childbirth.
b) Android or male pelvis: The pubic arch forms an acute angle, making
lower dimensions of the pelvis extremely narrow. Fetus may have
difficulty exiting from this type.
c) Anthropoid or ape-like pelvis: transverse diameter is narrow,
anteroposterior diameter of the inlet is larger than usual. Shape of pelvis
does not accommodate a fetal head as well as gynecoid pelvis.
d) Platypelloid or flattened pelvis: pelvis has smoothly curved oval inlet but
the anteroposterior diameter is shallow. Fetal head might not able to rotate
to match curves of pelvic cavity.

Internal Pelvic Measurements:

 a) Diagonal conjugate- measurement between anterior surface of sacral
prominence and the posterior surface of symphysis pubis. -
average: 10.5 cm to 11 cm
b) Ischial tuberosity- the distance between the ischial tuberosities or transverse
diameter of the outlet.
-made at the medial and lowermost aspect of the ischial
tuberosities at the level of anus.
-a diameter of 11 cm is considered adequate because the fetal head
has 9 cm

E. Laboratory Assessment

1. Urinalysis
Urine is tested for proteinuria (protein in urine), glycosuria (glucose in urine), nitrites
(bacteria in urine), and pyuria 9white blood cells in urine)

2. Blood serum Studies

Obtained at prenatal visit:
a) Complete blood count, including hemoglobin or hematocrit and red cell index
b) A genetic screen for common ethically inherited diseases
c) A serologic test for syphilis laboratory or rapid plasma regain
d) Blood typing
e) Cultures for chlamydia and gonorrhea
f) Maternal serum α-fetoprotein (MSAFP) and pregnancy-associated plasma protein
A
g) An indirect Coombs test
h) Serum antibody titers for rubella, hepatitis b, hepatitis C, varicella
i) HIV screening
j) 50 g oral 1 hour glucose loading or tolerance test.

3. Tuberculosis Screening
A small amount (0.1 ml) of tuberculin units are injected by a needle and syringe
intradermally
Can be also be done by a blood serum test called an interferon-gamma release assay
(IGRA)

4. Ultrasonography
May also be done ideally between 11 and 13 weeks of pregnancy

F. Risk Assessment (pp. 252, table 11.7: assessments that might categorize a pregnancy at
risk)

G. Signs Indicating Possible Complications of Pregnancy

 Assure a woman you have every reason to believe she is going to have normal,
uncomplicated pregnancy, she can informe her healthcare provider by telephone or
email
 Be certain you give her an alternate contact number to call if the healthcare facility is
closed.
 Assure her as well that if one of these danger signs should occur, it serves merely as
a signal of the possibility that something may be happening.
 A pregnant should report the following symptoms immediately:
 Vaginal bleeding
 Persistent vomiting
 Chills and fever or pain on urination
 Sudden escape of clear fluid from the vagina
 Abdominal or chest pain
 Gestational hypertension
 Increase or decrease fetal movement
 Uterine contractions before 37 weeks of pregnancy