Prenatal



Prenatal





Taking an obstetric history

When taking the pregnant patient’s obstetric history, make sure to ask her about:



  • genital tract anomalies


  • medications used during this pregnancy


  • history of hepatitis, PID, acquired immunodeficiency syndrome, blood transfusions, and herpes or other STDs


  • partner’s history of STDs


  • previous abortions


  • history of infertility.


Pregnancy particulars

Also ask the patient about past pregnancies. Make sure to note the number of past full-term and preterm pregnancies and obtain the following information about each of the patient’s past pregnancies, if applicable:



  • Was the pregnancy planned?


  • Did any complications—such as spotting, swelling of the hands and feet, surgery, or falls—occur?


  • Did the patient receive prenatal care? If so, when did it start?


  • Did she take any medications? If so, what were they? How long did she take them? Why?


  • What was the duration of the pregnancy?


  • How was the pregnancy overall for the patient?


Birth and baby specifics

Also obtain the following information about the birth and postpartum condition in all previous pregnancies:



  • What was the duration of labor?


  • What type of birth was it?


  • What type of anesthesia did the patient have, if any?


  • Did the patient experience complications during pregnancy or labor?


  • What were the birthplace, condition, gender, weight, and Rh factor of the neonate?


  • Was the labor as she had ex-pected it? Better? Worse?


  • Did she have stitches after birth?


  • What was the condition of the neonate after birth?


  • What was the neonate’s Apgar score?


  • Was special care needed for the neonate? If so, what?


  • Did the neonate experience problems during the first several days after birth?


  • What’s the child’s present state of health?


  • Was the neonate discharged from the health care facility with the mother?


  • Did the patient experience postpartum problems?



Summarizing pregnancy information

Typically, an abbreviation system is used to summarize a woman’s pregnancy information. Although many variations exist, a common abbreviation system consists of five digits—GTPAL.



  • Gravida = the number of pregnancies, including the present one.


  • Term = the total number of infants born at term or 37 or more weeks.


  • Preterm = the total number of infants born before 37 weeks.


  • Abortions = the total number of spontaneous or induced abortions.


  • Living = the total number of children currently living.

For example, if a woman pregnant once with twins delivers at 35 weeks’ gestation and the neonates survive, the abbreviation that represents this information is “10202.” During her next pregnancy, the abbreviation would be “20202.”

An abbreviated but less informative version reflects only the Gravida and Para (the number of pregnancies that reached the age of viability—generally accepted to be 24 weeks, regardless of whether or not the babies were born alive).

In some cases, the number of abortions also may be included. For example, “G3, P2, Ab1” represents a woman who has been pregnant three times, who has had two deliveries after 24 weeks’ gestation, and who has had one abortion. “G2, P1” represents a woman who has been pregnant two times and has delivered once after 24 weeks’ gestation.


Formidable findings

When performing the health history and assessment, look for the following findings to determine if a pregnant patient is at risk for complications.


Demographic factors



  • Maternal age younger than 16 years or older than 35 years


  • Fewer than 11 years of education


Lifestyle



  • Smoking (> 10 cigarettes/day)


  • Substance abuse


  • Long commute to work


  • Refusal to use seatbelts


  • Alcohol consumption


  • Heavy lifting or long periods of standing


  • Lack of smoke detectors in home


  • Unusual stress



Obstetric history



  • Infertility


  • Grand multiparity


  • Incompetent cervix


  • Uterine or cervical anomaly


  • Previous preterm labor or birth


  • Previous cesarean birth


  • Previous infant with macrosomia


  • Two or more spontaneous or elective abortions


  • Previous hydatidiform mole or choriocarcinoma


  • Previous ectopic pregnancy


  • Previous stillborn neonate or neonatal death


  • Previous multiple gestation


  • Previous prolonged labor


  • Previous low-birth-weight infant


  • Previous midforceps delivery


  • Diethylstilbestrol exposure in utero


  • Previous infant with neurologic deficit, birth injury, or congenital anomaly


  • < 1 year since last pregnancy


Medical history



  • Cardiac disease


  • Metabolic disease


  • Renal disease


  • Recent UTI or bacteriuria


  • GI disorders


  • Seizure disorders


  • Family history of severe inherited disorders


  • Surgery during pregnancy


  • Emotional disorders or mental retardation


  • Previous surgeries, particularly involving reproductive organs


  • Pulmonary disease


  • Endocrine disorders


  • Hemoglobinopathies


  • STD


  • Chronic hypertension


  • History of abnormal Pap smear


  • Malignancy


  • Reproductive tract anomalies


Current obstetric status



  • Inadequate prenatal care


  • Intrauterine growth–restricted fetus


  • Large-for-gestational-age fetus


  • Gestational hypertension


  • Abnormal fetal surveillance tests


  • Polyhydramnios


  • Placenta previa


  • Abnormal presentation


  • Maternal anemia


  • Weight gain of < 10 lb (4.5 kg)


  • Weight loss of > 5 lb (2.3 kg)


  • Overweight/underweight status


  • Fetal or placental malformation


  • Rh sensitization


  • Preterm labor


  • Multiple gestation


  • PROM


  • Abruptio placentae


  • Postdate pregnancy


  • Fibroid tumors


  • Fetal manipulation


  • Cervical cerclage


  • Maternal infection


  • Poor immunization status


  • STD





Psychosocial factors



  • Inadequate finances


  • Social problems


  • Adolescent


  • Poor nutrition, poor housing


  • More than two children at home with no additional support


  • Lack of acceptance of pregnancy


  • Attempt at or ideation of suicide


  • No involvement of baby’s father


  • Minority status


  • Parental occupation


  • Inadequate support systems


  • Dysfunctional grieving


  • Psychiatric history


Making sense out of pregnancy signs

This chart organizes signs of pregnancy into three categories: presumptive, probable, and positive.
































































































Sign Time from implantation (in weeks) Other possible causes
Presumptive
Breast changes, including feelings of tenderness, fullness, or tingling and enlargement or darkening of areola 2

  • Hyperprolactinemia induced by tranquilizers
  • Infection
  • Oral hormonal contraceptives
  • Prolactin-secreting pituitary tumor
  • Pseudocyesis
  • Premenstrual syndrome
Nausea or vomiting upon arising 2

  • Gastric disorders
  • Infections
  • Psychological disorders, such as pseudocyesis and anorexia nervosa
Amenorrhea 2

  • Anovulation
  • Blocked endometrial cavity
  • Endocrine changes
  • Medications (phenothiazines, Depro-Provera)
  • Metabolic changes
Frequent urination 3

  • Emotional stress
  • Pelvic tumor
  • Renal disease
  • UTI
Fatigue 12

  • Anemia
  • Chronic illness
  • Depression or stress
Uterine enlargement in which the uterus can be palpated over the sym-physis pubis 12

  • Ascites
  • Obesity
  • Uterine or pelvic tumor
Quickening (fetal movement felt by the woman) 18

  • Excessive flatus
  • Increased peristalsis
Linea nigra (line of dark pigment on the abdomen) 24

  • Cardiopulmonary disorders
  • Estrogen-progestin hormonal contraceptives
  • Obesity
  • Pelvic tumor
Melasma (dark pigment on the face) 24

  • Cardiopulmonary disorders
  • Estrogen-progestin hormonal contraceptives
  • Obesity
  • Pelvic tumor
Striae gravidarum (red streaks on the abdomen) 24

  • Cardiopulmonary disorders
  • Estrogen-progestin hormonal contraceptives
  • Obesity
  • Pelvic tumor
Probable
Laboratory tests revealing the presence of hCG hormone in blood or urine 1

  • Choriocarcinoma (urine hCG)
  • Hydatidiform mole (blood hCG)
Chadwick’s sign (vagina changes color from pink to violet) 6

  • Hyperemia of cervix, vagina, or vulva
Goodell’s sign (cervix softens) 6

  • Estrogen-progestin hormonal contraceptives
Hegar’s sign (lower uterine segment softens) 6

  • Excessively soft uterine walls
Sonographic evidence of gestational sac in which characteristic ring is evident 6

  • None
Ballottement (fetus can be felt to rise against abdominal wall when lower uterine segment is tapped during bimanual examination) 16

  • Ascites
  • Uterine tumor or polyps
Braxton Hicks contractions (periodic uterine tightening) 20

  • Gastric upset
  • Hematometra
  • Uterine tumor
Palpation of fetal outline through abdomen 20

  • Subserous uterine myoma
Positive
Sonographic evidence of fetal outline 8

  • None
Fetal heart audible by Doppler ultrasound 10 to 12

  • None
Palpation of fetal movement through abdomen 20

  • None



Physiologic adaptations to pregnancy


Cardiovascular system



  • Cardiac hypertrophy


  • Displacement of the heart


  • Increased blood volume and heart rate


  • Supine hypotension


  • Increased fibrinogen and hemoglobin levels


  • Decreased hematocrit


Gastrointestinal system



  • Gum swelling


  • Lateral and posterior displacement of the intestines


  • Superior and lateral displacement of the stomach


  • Delayed intestinal motility and gastric and gallbladder emptying time


  • Constipation


  • Displacement of the appendix from McBurney’s point


  • Increased tendency of gallstone formation


Endocrine system



  • Increased basal metabolic rate (up 25% at term)


  • Increased iodine metabolism


  • Slight parathyroidism


  • Increased plasma parathyroid hormone level


  • Slightly enlarged pituitary gland


  • Increased production of prolactin


  • Increased cortisol level


  • Decreased maternal blood glucose level


  • Decreased insulin production in early pregnancy


  • Increased production of estrogen, progesterone, and human chorionic somatomammotropin


Respiratory system



  • Increased vascularization of the respiratory tract


  • Shortening of the lungs


  • Upward displacement of the diaphragm


  • Increased tidal volume, causing slight hyperventilation


  • Increased chest circumference (by about 23/8″ [6 cm])


  • Altered breathing, with abdominal breathing replacing thoracic breathing as pregnancy pro-gresses


  • Slight increase (two breaths/minute) in respiratory rate


  • Increased pH, leading to mild respiratory alkalosis



Metabolic system



  • Increased water retention


  • Decreased serum protein level


  • Increased intracapillary pressure and permeability


  • Increased serum lipid, lipoprotein, and cholesterol levels


  • Increased iron requirements and carbohydrate needs


  • Increased protein retention


  • Weight gain of 25 to 30 lb (11.3 to 13.6 kg)


Integumentary system



  • Hyperactive sweat and sebaceous glands


  • Hyperpigmentation


  • Darkening of nipples, areolae, cervix, vagina, and vulva


  • Pigmentary changes in nose, cheeks, and forehead (facial chloasma)


  • Striae gravidarum and linea nigra


  • Breast changes (such as leaking of colostrum)


  • Palmar erythema and increased angiomas


  • Faster hair and nail growth with thinning and softening


Genitourinary system

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Jul 26, 2016 | Posted by in PEDIATRICS | Comments Off on Prenatal

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