Assessing Fetal And Maternal Health

ASSESSING FETAL AND MATERNAL HEALTH:

PRENATAL CARE

 Prenatal

care, essential for ensuring the overall health of newborns and their mothers, is a major strategy for helping to reduce the number of lowbirth weight babies born yearly .It is seen as so important that a number of National Health Goals speak directly to it. Ideally, prenatal care begins during the mother’s childhood. It includes balanced nutrition with adequate intake of calcium and vitamin D during infancy and childhood to prevent rickets(which can distort pelvic size);adequate immunizations against contagious diseases for protection against viral diseases such as rubella during

Nursing process overview For prenatal care: 1. assessment The first prenatal visit is a time to establish baseline data relevant to health assessment and planning health promotion strategies now and with every subsequent visit. Explaining why specific assessment data are relevant to the pregnancy maybe the first step in this process 2.nursing diagnosis although most woman probably have used a home pregnancy detection kit to find out if they pregnant, the first prenatal visit officially serves to confirm this, so nursing diagnosis may focus on the response of the woman and her family to that information for example: 

Decisional conflict related to desire to be pregnant



Risk for ineffective coping related to confirmation of unplanned pregnancy.

Nursing diagnoses appropriate to prenatal care in general include:  Health seeking behaviors related to guidelines for nutrition and activity during pregnancy.  Deficient knowledge regarding exposure to teratogens during pregnancy.  Risk for injury to fetus related to current lifestyle behaviors.

3. Outcome identification and planning Sufficient time should be reserved at prenatal visits so they can be thorough, allowing enough time to set realistic goals and expected outcomes with both the woman and her partner, if desired. Make sure that a woman leaving an initial prenatal visit schedules an appointment for a following visit, as this may not occur to a woman who may be excited or overwhelmed by

4. Implementation: The purposes of prenatal care are to:     



Establish a baseline of the present health. Determine the gestational age of the fetus. Monitor fetal development identify woman at risk for complications. Minimize the risk of possible complications by anticipating and preventing problems before they occur. Provide time for education about pregnancy, lactation and newborn care. During prenatal visits, much time is spent on teaching about prenatal care. It may be helpful to give a woman and her partner pamphlets or books that cover the same topics. This preparation helps to ensure that a pamphlets advice is consistent with what you have already

5. Outcome evaluation Evaluation during prenatal visits should concentrate on the woman’s initial progress toward understanding goals of care for pregnancy and assessing outcomes established for specific diagnoses. Examples of expected outcomes might include:  Couple states they have reached a decision about maintaining or discounting the pregnancy.  Client states she feels well informed about the common discomforts of pregnancy and

HEALTH PROMOTION DURING PREGNANCY The Preconceptual Visit:  



Ideally, women schedule appointments with a physician or nurse-midwife before becoming pregnant TO OBTAIN ACCURATE REPRODUCTIVE LIFE PLANNING INFORMATION, RECEIVE REASSURANCE ABOUT FERTILITY(AS MUCH AS CAN BE GIVEN BASED ON A HEALTH HISTORY AND A ROUTINE PHYSICAL EXAMINATION),AND DETECT ANY PROBLEMS THAT MAY NEED CORRECTION THROUGH HEALTH HISTORY, PELVIC EXAMINATION AND PAPANICOLAU(PAP) TEST. At this visit, hemoglobin level and blood type (including Rh factor) can be determined; minor vaginal infections such as those arising from Candida or CHLAMYDIA can be corrected to help ensure fertility; and the woman can be counseled on the importance of good protein diet, adequate intake of FOLIC ACID, and early prenatal care if she does become pregnant.

Choosing a Health Care Provider for Pregnancy and Childbirth

 Once

a woman is or suspects that she may be pregnant, she chooses a primary health care provider to care for her throughout the pregnancy and birth. Various options are available, INCLUDING A PRENATAL CLINIC, HER HMO HEALTH CARE PROVIDER, A NURSE MIDWIFE, AN OBSTERICIAN, OR A FAMILY PRACTITIONER.  Nurses can contribute to the success of prenatal care by listening, counseling, and teaching,-three areas of nursing expertise.

HEALTH ASSESMENT DURING THE FIRST PRENATAL VISIT 

Prenatal care is important because lack of it is associated with the birth of preterm infants and various complications for the woman. The major causes of death during pregnancy today for women are ECTOPIC PREGNANCY, HYPERTENSION, HEMORRHAGE, EMBOLISM, INFECTION, AND ANESTHESIA-RELATED COMPLICATIONS SUCH AS ANTRAPARTUM CARDIAC ARREST. An important focus of all prenatal visits, therefore, IS TO SCREEN FOR DANGER SIGNS THAT MIGHT REVEAL ANY OF THESE CONDITIONS.



The first visit includes an extensive health history complete physical examination, including pelvic examination, and blood and urine specimens for

THE INITIAL INTERVIEW 

Interviewing expectant women often elicits contradictory information. Women are likely to want to talk about their past health and current pregnancy, so interviewing them should go smoothly and be productive. On the other hand, pregnancy symptoms are subtle, so a woman may not regard certain information as important, providing vague answers to questions about these areas. Perhaps she is unaware that she is the only person who knows the answers to a number of vital questions-(how do you feel about being pregnant? Or have you been taking anything for your morning nausea?)

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Interviewing is best accomplished in a private, quiet setting. Trying to talk to a woman in a crowded hallway or a full waiting room is rarely

 It

is helpful if the person scheduling the appointment cautious a woman that the first visit may be long. This prevents her from trying to fit the visit in between other errands or from having to terminate the interview because of another appointment.

 Be

certain to ask what name a woman wants you to use when addressing her in a prenatal setting, and make certain that she knows your name and understands your role correctly. If she views you as someone only gathering preliminary data, she will be willing to discuss superficial facts (name, address, phone number, and the like) but will resist discussing more intimate things (her feelings

 Because

initial health history taking is often time-consuming, a woman may be asked to complete some of the forms. Good interviewing technique, however, is important to obtain thorough and meaningful health histories. The rapport established by face-to-face interviewing gives a woman the feeling that she is more than just a client number or chart. It may be as much a reason she returns for followup care as her desire to be assured that her pregnancy is progressing normally.

Components of the Health History

An initial interview serves several purposes:  Establishing rapport  Gaining

information about the woman’s physical and psychosocial health

 Obtaining

a basis for anticipatory guidance for the pregnancy

Establishing a baseline health picture at the initial pregnancy visit is important. If on subsequent visits a symptom is mentioned, you can then check your records to verify that it is truly a new symptom. It may be that the woman is just becoming more aware of it. General interviewing techniques are discussed in. included in the following section are the elements pertinent to a pregnancy history.

Demographic Data Demographic

data usually obtained include name, age, address, telephone number, religion, and health insurance information.

Chief Concern 

The chief concern is the reason the woman has come to the health care setting − in this instance, the fact that she is or thinks she is pregnant.



To help confirm pregnancy, inquire about the date her last menstrual period and whether she has had a pregnancy test or used a home test kit. Elicit information about the signs of early pregnancy, such as nausea, vomiting, breast changes, or fatigue. Question her about any discomforts of pregnancy, such as constipation, backache, or frequent urination. Also, ask about any danger signs of pregnancy, such as

 Ask

if the pregnancy was planned. If you feel uncomfortable asking directly, using a statement such as, “All pregnancies area bit of surprise. Is that how it was with this one?” may help provide you with this information. Another way to word such a question would be, “Some couples plan on having children right away; some plan on waiting. How was it with you?” If the woman says the pregnancy was not planned, explore to learn if she has reached a decision about whether to continue with the pregnancy. A question such as, “Some women change their mind about wanting a baby once they realize they are pregnant; some don’t. How has it been for you?” may be effective for obtaining this type of information because

Family Profile  In

the past, the social history or family setting history (family profile) was left until the end of a health interview. More often, it is now obtained at the beginning of the interview, following the chief concern. Doing so can help you get to know a woman earlier, identify support persons, shape the nature and kind of questions asked, and evaluate the possible impact of the client’s culture on care.

 Ask

about marital status. As a rule both married and unmarried women want you to know this as they want to alert you if they do not have support people readily available.

 It

is important to know the size of the apartment or house in which a woman lives because you will be talking with her in the coming months about a bedroom or space for a baby’s bed. It also is important to know whether the essential rooms are on the ground floor or upstairs in case she is restricted from climbing stairs more than once or twice a day during the last part of pregnancy or after birth.

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Before you can begin to offer a woman any more than stereotyped health care instruction, get to know her and her sexual partner’s age(additional testing such as genetic screening may be necessary if she over 35),their educational levels(offers an estimation of the level of teaching you will plan),and occupation(does the woman’s work involve heavy lifting,long hours of standing in one position, handling of a toxic substance?)

 Adaptation

to pregnancy is individualized. No one in the health care setting will be aware of these potentially harmful situations unless questions about family profile are asked.

History of Past Illnesses 

Questions about a woman’s past medical history are an important part of an interview because a past condition may become active during or immediately following pregnancy.

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Representative diseases that can pose a potential difficulty during pregnancy include kidney disease , heart disease(coarctation of the aorta and rheumatic fever cause problems most often), hypertension, sexually transmitted infection(including hepatitis B and human immunodeficiency virus [HIV]), diabetes, thyroid disease, recurrent seizures, gallbladder disease, urinary tract infections, varicosities, phenylketonuria, tuberculosis, and asthma.

 It

is important to find out whether a woman had childhood disease such as chickenpox(varicella), mumps(epidemic parotitis), measles (rubeola), German measles (rubella), or poliomyelitis. From this information, you can estimate the degree of antibody protection the client has against these diseases if she is exposed to them during her pregnancy.

 While

pregnant she can be immunized against poliomyelitis by the Salk(killed virus) vaccine. However she cannot be immunized against the other diseases because the vaccines against these contain live viruses, as does the oral Sabin poliomyelitis vaccine. Live virus vaccines could be harmful to the fetus if

 Also

ask about any allergies, including any drug sensitivities. As a rule women with allergies of any magnitude should be urged to breast-feed rather than bottle feed their infants to avoid possible milk allergy in the infant. Any past surgical procedures are also important because adhesions resulting from past abdominal surgery may interfere with uterine growth.

HISTORY OF FAMILY ILLNESSES 

A family history documents illnesses that occur frequently in the family and helps to identify potential problems in the mother during pregnancy or in the infant at birth ask specifically about cardiovascular and renal disease cognitive impairment, blood disorders, or any known genetically inherited diseases or congenital

DAY HISTORY/SOCIAL PROFILE 

Nutrition is an important part of a day history to a obtain, particularly in light of the number of young adults with eating disorders today. A “24-hour recall” is helpful to obtain accurate nutrition information because by doing this, the woman tells you what she actually ate, not what she should have eaten.

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Ask about the type, amount, and frequently of exercise to determine her routine pattern and whether it will be consistent with a recommended level for pregnancy. If she hikes or camps, she is risk for exposure to Lyme disease. Ask about hobbies. Certain hobbies, such as working with lead-based

 Because

smoke, whether first-hand or second-hand, has been shown to be harmful to fetal growth, obtain information about the client’s smoking habits. Excessive alcohol intake can lead to poor nutrition, can be directly responsible for fetal alcohol syndrome, and may cause preterm birth. If a woman answers vaguely about how she smokes or drinks alcohol (“I drink socially” or “I only smoke occasionally), attempt to determine exactly what she means so you can more accurately evaluate the frequency of these events.

 Pregnant

women, especially adolescents,

A

medication history is also important. Ask whether the woman takes any medications, prescribed or over-thecounter, because their effect on a growing fetus will have to be evaluated. This also includes any herbal preparations that a woman might be using. For example, isotretinoin (accutane), a vitamin A preparation taken for acne, is associated with spontaneous miscarriage and congenital anomalies. Herbal supplements should be evaluated carefully before being taken by pregnant women to be certain they don’t stimulate uterine contractions.

 Ask

about the use of any recreational drugs, such as marijuana or cocaine, as these also can be deleterious to fetal

GYNECOLOGIC HISTORY  Obtain

information about her age of menarche (first menstrual period) and how well she was prepared for it as a normal part of life. Ask about her usual cycle, including the interval, duration, amount of menstrual flow, and any discomfort she feels. If she describes menstrual cramps as “horrible” and wonders “how I live through them some months”, anticipate the need for additional counseling to help her prepare for labor.

 Anticipate

their need for counseling in the postpartum period about active ways to relieve their menstrual discomfort when their



Also ask if a woman does a monthly perineum self examination to evaluate her interest in self-care routine. Breast self-examination is no longer thought to yield enough reliable information to be continued as a self-care routine.

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Ask about past surgery on the reproductive tract. If she has had uterine surgery, a cesarean birth may be necessary because her uterus may not be able to expand and contract as efficiently as usual because of the surgical scar.

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Ask also about what reproductive planning methods, if any, have been used. Occasionally, a woman may become pregnant with an intrauterine device (IUD) in place. If this occurs, it will be removed to prevent infection during pregnancy. Be certain to include a sexual history, including the number of sexual partners and use of safe sex practices, to establish the woman’s risk for contracting a sexually transmitted

 As

a part of any woman’s gynecologic history, assess for the possibility of stress incontinence (incontinence of urine on laughing, coughing, deep inspiration, jogging, or running).

 Commonly,

weakness occurs from difficult births, the birth of large infants, grand multiparity, and instrumented births. During pregnancy stress incontinence can become intensified from the increasing abdominal pressure.

 Women

can relieve stress incontinence to some degree by strengthening the perineal muscles with the use of Kegel

OBSTETRIC HISTORY For each previous pregnancy, document the child’s sex and the place and date of birth. Review the pregnancy briefly: Was it planned?  Did she have any complications, such as spotting, swelling of her hands or feet, falls, or surgery?  Did she take any medication? If so, what and why?  Did she receive prenatal care? When did she start?  What was the duration of the pregnancy  What was the duration of labor?  Was labor what she expected? Worse? Better? 

 Did

she have stitches following birth?  Did she have any complications, such as excessive bleeding or infection following the birth?  What was the infant’s birthweight and sex?  What was the condition of the infant at birth? Did the infant cry right away?  What was the infant’s Apgar score?  Was any special care needed for the baby, such as suctioning, oxygen, or an incubator?  Was the baby discharged from the health care setting with her?  What is the child’s present state of health?

 Ask

about any previous miscarriages or abortions and whether she had any complications during or following them. If the woman’s blood type is Rh negative, ask if she received Rh immune globulin (RhiG[RhoGAM]) after miscarriages or abortions or previous births so you will know whether Rh sensitization could have occurred.  Ask if she has ever had a blood transfusion to establish possible risk of hepatitis B or HIV exposure or Rh sensitization.

 After

a history of previous pregnancies is obtained, determine the woman’s status with respect to the number of times she has been pregnant, including the present pregnancy (gravida), and the number of children and the number of children above the age of viability she has previously born (para).  Age of viability- is the earliest age at which fetuses could survive if they were born at that time, generally accepted as 24 weeks, or fetuses weighing more than 40 g.  Gravida- a woman who is or has been pregnant.  Para- the number of pregnancies that

A more comprehensive system for classifying pregnancy status (GTPAL or GTPALM) provides greater detail on a woman’s pregnancy history. By this system, the gravida classification remains the same, but para is broken down into:  T: The number of full-term infants born (infants born at 37 weeks or after)  P: The number of preterm infants born (infants born before 37 weeks)  A: The number of spontaneous or induced abortions.  L: The number of living children.

REVIEW OF SYSTEMS 

A review of systems completes the subjective information. Use a systematic approach, such as head to toe, and explain what you’ll be doing. The following body systems and questions about conditions constitute the minimum information to be addressed in a review of systems for a first prenatal visit:

Head: Headache? Head injury? Seizures? Dizziness? Fainting?  Eyes: Vision? Glasses needed? Diplopia? Infection? Glaucoma? Cataract? Pain? Recent changes?  Ears: Infection? Discharge? Earache? Hearing loss? Tinnitus? Vertigo? 

Nose:

Epistaxis (nose bleeds)? Discharge? How many colds a year? Allergy? Postnatal drainage? Sinus pain? Mouth and Pharynx: Dentures? Condition of teeth? Tootaches? Any bleeding of gums? Hoarseness? Difficulty in swallowing? Tonsillectomy? Neck: Stiffness? Masses?

 Breasts:

Lumps? Secretion? Pain? Tenderness?  Respiratory system: Cough? Wheezing? Asthma? Shortness of breath? Pain? Serious chest illness, such as tuberculosis or pneumonia?  Cardiovascular system: History of heart murmur? History of heart disease such as rheumatic fever or Kawasaki Disease? Hypertension? Any pain? Palpitations? Anemia? Does she know her blood pressure?

 Gastrointestinal

System: What was her prepregnency weight? Vomiting? Diarrhea? Constipation? Change in bowel habits? Rectal pruritus? Hemorrhoids? Pain? Ulcer? Gallbladder disease? Hepatitis? Appendicitis?  Genitourinary System: Urinary Tract Infection? Hematuria? Frequent urination? Sexually Transmitted infection? Pelvic inflammatory disease? Hepatitis B? HIV?  Extremities: Varicose veins? Pain or stiffness of joints? Any fractures or

CONCLUSION End

an interview by asking if there is something you have not covered that the woman wants to discuss. This gives her one more chance to ask any questions she has about this new life experience.

SUPPORT PERSON’S ROLE  If

family members are present, should they be included in an initial interview? As a whole, interviewing is most effective if it’s one-to-one interaction.

 If

childbearing is to be a family affair, however, it is important to determine the partner’s degree of acceptance of the pregnancy and of assuming a new parenting role.

 Interviewing

the woman alone and then inviting the support person and family to join her while you talk about pregnancy symptoms with them as a family is an effective solution. Providing some private interview time with the partner allows the partner to express any concerns or worries.

 After

the confirmation of pregnancy, the partner should be included when health care information is given.