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 low-
birth 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?)

 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
 Itis 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 follow-
up 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

 Obtaininga 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.
 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.

 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.
 Itis 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
 Alsoask 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.

 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-the-
counter, 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.

 Askabout 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.

 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.

 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
 Asa 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
 Iffamily 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.

 Ifchildbearing 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.