1. Admission Assessment of the Pregnant Woman
Evelyn M. Hickson, RN, MSN, CNS, WCC

2. Objectives
Identify potential complications of pregnancy based on prenatal history, physical assessment and lab values.
Discuss the role of the perinatal nurse in screening, identifying, documenting and referring patients with history of domestic violence or substance use during pregnancy.
Discuss maternal infections, modes of treatment, and potential impact on the infant.
(HIV TB, STDs, Hepatitis, Herpes, GBS)

3. Review of Prenatal Records
Review office reports, including
Obstetrical history
Personal medical history
Family history
Social history
Note any areas of concern identified by the care provider
Family history concerns: cardiac disease, DM, bleeding disorders
Examples of pregnancy-related concerns: previous postpartum hemorrhage, previous c-section, previous stillborn, previous preterm labor or birth, elevated blood pressures during pregnancy, gestational diabetes, etc.

4. Prenatal Labs Blood type and antibody screen Rubella immunity
GBS culture
HSV
HIV
Hepatitis B
VDRL/RPR
Quad screen
Glucose tolerance testing

5. OB History: Current Pregnancy
Maternal age
EDC
Dating criteria
How early did she start prenatal care?
Gestation
Current complications
GTPAL
Gravidity
Term births
Preterm (<37 wk) births
Abortions (elective, therapeutic or spontaneous)
Living children
Early prenatal care allows for greater opportunity to identify potential medical or social risks for the patient and fetus and is associated with improved pregnancy outcomes. (Simpson and Creehan, 1996).
How many prenatal visits? Every 4 weeks the first 28 weeks of pregnancy, every 2 weeks until 36 weeks, then weekly until delivery.
Do they live with you? How old is your youngest child?
Occasionally when reviewing these events with patients they will remember pregnancies that they did not report to their care provider. How fresh their memories are for childbirth could be influenced by how many years back was the last baby.

6. OB History: Multiparous Patients
Length of previous labors, infant birth weight, gestational age at delivery
History of preterm labor or delivery
Previous operative delivery
Previous stillbirth
History of postpartum hemorrhage or postpartum depression

7. Social History Marital status or available family support
CPS or other alerts
Social/economic/educational concerns
Physical/mental challenges
Referral to social services
Language barriers
Religious or cultural practices

8. Prioritizing the Patient Interview
Sometimes the urgency of the situation dictates the order in which one proceeds with a patient interview, such as:
Imminent delivery
Unstable maternal condition (Unconscious, bleeding, seizing, etc)
Category 3 fetal tracing
Appropriate to gather information from support people that may be present in either of these situations.

9. Patient Interview Note the date and time of patient arrival
Is your baby moving?
Are you contracting? If so, when did they start and how often are they occurring?
Are you experiencing vaginal bleeding, discharge, or leaking of fluid?
Are you in pain? Orient the patient to the pain scale and discuss her plans for pain management.
Send them to bathroom for UA.
What brings you here?
Have you had intercourse in the past 12 to 24 hours?
Consider posting crisis card line in bathroom, so that women experiencing domestic violence may discreetly get information.

10. Patient Interview (cont.)
Current medications
Dose, route, last taken
Allergies and reactions
When the patient last ate or drank (including what was eaten or drunk)
Recent SVE
Complications with current or previous pregnancy

11. Is the patient experiencing…
Nausea or vomiting
Frequency or burning with urination
Epigastric pain
Headaches
Visual disturbances

12. Physical Assessment Leopold’s Maneuvers EFM
Orient patient to monitors and basic strip interpretation
When you are doing a physical assessment, look for any unusual marks or bruises. Note patient’s demeanor and reactions to procedures. Make sure she understands what you are going to do and why before you proceed.
Ask: what are some contraindications to an SVE?

13. Physical Assessment Vital signs (full set) Urine dip
Physical exam including:
Edema
DTRs and Clonus
Breath sounds if patient presents with respiratory symptoms
SVE – unless contraindicated

14. Labor Assessment Time contractions started
Frequency, duration, and regularity of contractions
Palpation of maternal abdomen during and between contractions
Fetal movement
Pain assessment, including location and type of pain

15. Herbs/Foods That Increase Uterine Activity
Bitter Melon
Castor bean or castor oil
Chamomile tea
Cinnamon (spice tea)
Garlic
Ginger
Goldenseal
Pomegranate
Red raspberry leaf tea

16. Suspected Rupture of Membranes
Intercourse in last hours
Time possible SROM occurred
Color, amount, and smell of fluid
Testing of vaginal discharge for presence of amniotic fluid
If the patient is between 24 and 34 weeks gestation, sterile speculum exam for testing of ROM and collection of FFN may be indicated.

17. Substance Use and Abuse
Warning signs of drug abuse:
Noncompliance with prenatal care – late entry or no prenatal care
Poor nutrition –due to adolescence, obesity, low socioeconomic status
Current or previous history of encounters with law enforcement
Marital & family disputes
Intrapartum signs of substance abuse
Unexplained IUGR
3rd trimester stillbirth
Unexpected preterm birth
Placental abruption in a woman without hypertensive disorders.
Informed consent for testing
Social service consult, CPS, drug treatment
Questions need to be non-threatening and non-judgmental.
Questions like when have you last used…. Are sometimes helpful.

18. Domestic Violence
Majority of abused women continue to be victimized during pregnancy and may escalate. Most estimate rates between 4 –8%.
Child abuse occurs in 33 – 77% of families with adult abuse.
No single profile of an abused woman: all racial, economic, educational, religious, ethnic and social backgrounds.
Where will you find evidence of abuse on the patient’s body?
What kind of behavior do you assess in the abused patient and her abuser?

19. Pregnancy and Domestic Violence
Signs of domestic violence in the pregnant patient include:
unwanted pregnancy
late entry into prenatal care
missed appointments
substance abuse or use
poor weight gain and nutrition
multiple, repeated somatic complaints.

20. Domestic Violence Screening
Should be conducted in private, with only the patient present
“Because violence against women is so common, I ask all of my patients do you have any reason to feel unsafe at home?”
Document patient statements accurately and quote them directly

21. Promptly Notify Care Provider if:
Vaginal bleeding
Acute abdominal pain
Temperature of F or higher
Preterm labor
Preterm rupture of membranes
Hypertension
Non-reassuring fetal heart rate pattern

22. SBAR Communication Best method to speak to providers
Gives you a standard list of things you need to be prepared to discuss with them
Be concise and factual
Do not use “touchy-feely” language

23. SBAR Communication Situation What is going on with the patient?
Background
What is the clinical context?
Assessment
What do I think the problem is?
Recommendation
What would I do to correct it?
Remember that you may be speaking with a care provider that is not familiar with the patient.

24. SBAR Guideline Prior to calling the provider:
Have I assessed the patient myself?
Has the situation been discussed with a resource nurse or preceptor?
Have the following available when speaking:
Patient chart
List of current medications, allergies, whether IV was placed and labs drawn
Most recent vital signs
Reporting lab results: provide the date and time test was done and results of previous labs for comparison

25. SBAR: Situation What is the situation you are calling about?
Identify self, unit, patient, room number
State who the patient’s doctor has been for the pregnancy
Briefly state the problem, what is it, when it happened or started, and how severe.

26. SBAR: Background
Pertinent background information related to the situation could include:
Gestation, GTPAL, age, previously identified risk factors
List of current medications, allergies, labs
Most recent vital signs
Clinical information

27. SBAR: Assessment and Recommendation
What is your assessment of the situation?
What is your recommendation or expectation?
Admission for labor
Patient needs to be seen now
Patient needs antibiotics for UTI, etc.
Document the care provider notification, orders received, changes in patient condition, and plan.

28. Guidelines for Communication with Physicians Using SBAR
Use the following according to provider preference.
Direct page
Call service
During weekdays, the office directly
On weekends and after hours during the week, home phone
Cell phone.
Wait no longer than 5 minutes between attempts.
For emergent situations, use the appropriate chain of command as needed to ensure safe patient care.

29. References Guidelines for Perinatal Care, (6th ed.)/AAP and ACOG, 2005
Lowdermilk, D. and Perry, S. (2007). Maternity and Women’s Health Care (9th ed.). St. Louis, MI: Mosby Elsevier.
Mattson, S. and Smith, J. (2004). Core Curriculum for Maternal-Newborn Nursing (3rd ed.). St. Louis, MI: Mosby Elsevier.
Simpson, K. and Creehan, P. (2010). Perinatal Nursing (3rd ed.). Philadelphia, PA: Lippincott.