1. Dr. Areefa Al Bahri Chapter 3 The Prenatal Assessment

2. Introduction The objective of this chapter is to enhance understanding of the complexities and challenges involved in providing prenatal nursing care. Each prenatal visit offers an opportunity for the nurse to provide a comforting, supportive environment for the expectant woman and her family members. During these visits, educational needs can can be discussed, reassurance can be provided, and problems or potential problems can be discovered. Promoting maternal physical, psychological, and spiritual health and facilitating maternal empowerment are key to promoting and enhancing fetal well-being and a positive pregnancy outcome. throughout pregnancy are explored.

3. Goals that guide nursing care of the prenatal patient To recognize deviations from normal To provide individualized, evidence-based care To provide culturally appropriate prenatal education designed to meet the patient’s learning style and needs To empower women to become actively involved in their pregnancy by being informed recipients and shared decision makers.

4. Despite tremendous improvements in perinatal care, women still die in childbirth and it is not unrealistic for a woman to fear for her own safety. The World Health Report “Make Every Woman and Every Child Count” (World Health Organization 2005) focuses on making pregnancy safer and asserts that reaching this goal centers on providing excellent antenatal care and constructing societies that support pregnant women. Antenatal care must be consistently accessible and responsive while incorporating patient-centered interventions, thereby removing barriers that prevent access to care.

5. Prenatal Visit time Prenatal care usually begins in the first trimester of pregnancy, when the patient is seen every 4 weeks until she reaches 28 to 32 weeks’ gestation. At that time, the appointments are changed to visits every 2 weeks and then occur weekly from 36 weeks of gestation until birth. Although this schedule has to some extent become the “standard of care,” it has not been possible to substantiate the necessity for such frequent visits. Interestingly, the number of total prenatal visits varies tremendously from as few as 3 to 4 visits (less number) for low-risk women in some European countries to 14 or more visits for women with uncomplicated pregnancies in the United States (Partridge & Holman, 2005).

6. CARE Principles Communication The exchange of information by speaking, writing, or using a common system of signs or behavior or written message Advocate One who argues for a cause; a supporter or defender One who pleads in another’s behalf; Advocates for abused children and spouses Respect To show consideration or thoughtfulness in relation to somebody or something Enable To provide somebody with the resources, authority, or opportunity to do something To make something.

7. Choosing a Pregnancy Care Provider One of the early decisions the patient (and partner) makes concerns choosing a care provider. It is recommended that every patient arrange an appointment with a chosen care provider (obstetrician, family practice physician, certified nurse midwife) to discuss the management of pregnancy and childbirth as early as possible within the first trimester. The woman may seek childbearing care from an obstetrician, a family practice physician, or a certified nurse midwife. Approximately 90% of pregnant women choose an obstetrician as the primary care provider.

8. The First Prenatal Visit  The Comprehensive Health History  Comprehensive Obstetrics history  Biographical Data  Social History  Psychological Assessment

9. Presumptive Signs Of Pregnancy The subjective signs of pregnancy are the symptoms that the patient experiences and reports. Because these symptoms may be caused by other conditions, they are the least indicative of pregnancy. In combination with other pregnancy symptoms, the following presumptive signs may serve as diagnostic clues: 1.Amenorrhea 2.Nausea and vomiting (morning sickness) 3.Frequent urination 4.Breast tenderness 5.Perception of fetal movement (quickening) 6.Skin changes(striae gravidarum) 7.Fatigue

10. PROBABLE SIGNS OF PREGNANCY 1.Abdominal enlargement 2.Hegar sign (softening of the lower uterine segment) may also be caused by pelvic congestion. 3. Goodell sign may also be caused by infection, hormonal imbalance or pelvic congestion. 4.Chadwick may also be caused by pelvic congestion, infection, or a hormonal imbalance. 5. Braxton–Hicks sign also be associated with uterine leiomyomas (fibroids) or other tumors. 6.Positive pregnancy test may occur from certain medications, premature menopause, choriocarcinoma 7.Ballottement may be due to uterine tumors or cervical polyps instead of the presence of a fetus.

11. The positive indicators of pregnancy are attributable only to the presence of a fetus: 1. Fetal heartbeat 2.Visualization of the fetus 3. Fetal movements palpated by the examiner positive signs of pregnancy

12. Naegele’s Rule is used to calculate the Expected Date of Birth (EDB) – Expected Date of Delivery (EDD) This calculation is based on the first day of the woman’s last normal period. 7 days are added to the LMP and 3 months subtracted and where necessary a year added.

13. The Pregnancy Classification System Gravidity: relates to the number of times that a woman has been pregnant, irrespective of the outcome. nulligravida :a woman who has never experienced a pregnancy. primigravida: is a woman pregnant for the first time. A multigravida: pregnant for the third (or more times). Parity: pregnancies carried to a point of viability (500 g at birth or 20 weeks of gestation), regardless of the outcome. For example, “para 1” indicates that one pregnancy reached the age of viability. It is important to note that the term parity (or “para”) denotes the number of pregnancies, not the number of fetuses/babies, and does not reflect whether the fetuses/babies were born alive or stillborn.Some facilities use a digital system (i.e., GTPAL) for recording the number of pregnancies and their outcomes.

14. G Gravida T Number of Term pregnancies P Number of Preterm deliveries A Number of Abortions, both spontaneous and induced L Number of Living children

15. The Prenatal Physical Examination The patient should be given adequate private time to prepare for the examination and encouraged to void if needed (a urine specimen may also need to be collected). Before conducting the physical examination, it is essential to properly prepare the environment. The room should be warm, with a cover for the patient and a gown for her to wear. Ensure privacy for the patient, such as a “Do not disturb exam in progress” sign affixed to the closed door.

19. Abdominal Palpation for Fetal Position

20. Purpose 1.Determine the position of the baby in utero 2.Determine the expected presentation during labor and delivery

21. Questions to ask yourself when performing the abdominal palpation examination: 1.Is the fundal height consistent with the fetal maturity? 2.Is the, transvelie longitudinalrse or oblique? 3.Is the presentation cephalic or breech? 4.If cephalic, is the attitude vertex or facial? 5.What is the position of the denominator? 6.Is the vertex engaged?

22. The fetal lie is either:  Longitudinal o long axis of the fetus is alligned to the mother’s o this is the only NORMAL position  Transverse o long axis of the fetus is perpendicular to that of the mother’s  Oblique o long axis of the fetus is 0-90 degrees (or 90-180 degrees) to that of the mother’s

23. Fetal Lie

24. The presentation is either:  Vertex o head down in the pelvis  Brow  Facial  Breech o head is up in the uterine fundus and the buttocks is down in the pelvis  Shoulder

25. Attitude  The attitude is the relationship of the fetal parts to each other: o Flexed o Deflexed o Extended

26. Engagement  Determined by the amount of head that is above or below the pelvic brim o This is usually done by dividing the head into ”fifths” o if the head is still palpable abdominally, it is “2/5” or less engaged

27. Leopold’s Maneuver

28. PURPOSES  To provide information about fetal presentation, position, presenting part i.e. lie, attitude, and descent  To aid in location of fetal heart rates  To aid in assessment of fetal size  To determination of single versus multiple gestation

29. Leopold’s Maneuver  Four-part process  Palpation of fetal position in-utero

30. Preparation  Woman is supine, head slightly elevated and knees slightly flexed  Place a small rolled towel under her right hip If the nurse is R handed, stand at the woman’s R side facing her for the first 3 steps, then turn and face her feet for the last step (L handed, left side).

31. First Maneuver  Facing the mother, palpate the fundus with both hands –Assess for shape, size, consistency and mobility  Fetal head: firm, hard, and round –Moves independently of the rest –Detectable by ballotement  Breech/buttocks: softer and has bony prominences –Moves with the rest of the form

32. Second Maneuver Determine position of the back.  Still facing the mother, place both palms on the abdomen o Hold R hand still and with deep but gentle pressure, use L hand to feel for the firm, smooth back o Repeat using opposite hands  Confirm your findings by palpating the fetal extremities on the opposite side o small protrusions, “lumpy”

33. Third Maneuver Determine what part is lying above the inlet.  Gently grasp the lower portion of the abdomen (just above symphisis pubis) with the thumb and fingers of the R hand  Confirm presenting part (opposite of what’s in the fundus) (opposite of what’s in the fundus)

34.  Head will feel firm  Buttocks will feel softer and irregular  If it’s not engaged, it may be gently pushed back and forth  Proceed to the 4 th step if it’s not engaged…

35. Fourth Maneuver 1.Locate brow. 2.Assess descent of the presenting part.  Turn to face the woman’s feet  Move fingers of both hands gently down the sides of the abdomen towards the pubis - Palpate for the cephalic prominence (vertex)

36. Fourth Maneuver (cont’d)  Prominence on the same side as the small parts suggests that the head is flexed (optimum)  Prominence on the same side as the back suggests that the head is extended