Once pregnant, women require routine prenatal care to help safeguard their health and the health of the fetus. Also, evaluation is often required for symptoms and signs of illness. Common symptoms that are often pregnancy-related include Specific obstetric disorders and nonobstetric disorders in pregnant woman are discussed elsewhere. The initial routine prenatal visit should occur between 6 and 8 weeks gestation. Follow-up visits should occur at
Prenatal visits may be scheduled more frequently if risk of a poor pregnancy outcome is high or less frequently if risk is very low. Prenatal care includes
During the initial visit, clinicians should obtain a full medical history, including
During subsequent visits, queries focus on interim developments, particularly vaginal bleeding or fluid discharge, headache, changes in vision, edema of face or fingers, and changes in frequency or intensity of fetal movement. Gravidity is the number of confirmed pregnancies; a pregnant woman is a gravida. Parity is the number of deliveries after 20 weeks. Multifetal pregnancy is counted as one in terms of gravidity and parity. Abortus is the number of pregnancy losses (abortions) before 20 weeks regardless of cause (eg, spontaneous, therapeutic, or elective abortion; ectopic pregnancy). Sum of parity and abortus equals gravidity. Parity is often recorded as 4 numbers:
Thus, a woman who is pregnant and has had one term delivery, one set of twins born at 32 weeks, and 2 abortions is gravida 5, para 1-1-2-3. A full general examination, including blood pressure (BP), height, and weight, is done first. Body mass index (BMI) should be calculated and recorded. BP and weight should be measured at each prenatal visit. In the initial obstetric examination, speculum and bimanual pelvic examination is done for the following reasons:
Also, fetal heart
rate and, in patients presenting later in pregnancy, lie of the fetus are assessed (see figure Leopold maneuver
Leopold maneuver Pelvic capacity can be estimated clinically by evaluating various measurements with the middle finger during bimanual examination. If the distance from the underside of the pubic symphysis to the sacral promontory is > 11.5 cm, the pelvic inlet is almost certainly adequate. Normally, distance between the ischial spines is ≥ 9 cm, length of the sacrospinous ligaments is 4 to ≥ 5 cm, and the subpubic arch is ≥ 90°. During subsequent visits, BP and weight assessment is important. Obstetric examination focuses on uterine size, fundal height (in cm above the symphysis pubis), fetal heart rate and activity, and maternal diet, weight gain, and overall well-being. Speculum and bimanual examination is usually not needed unless vaginal discharge or bleeding, leakage of fluid, or pain is present.
Generally, women are routinely screened for gestational diabetes between 24 and 28 weeks using a 50-g, 1-hour
glucose tolerance test
Diabetes
If the 1st-trimester test is normal, the 50-g test should repeated at 24 to 28 weeks, followed, if abnormal, by a 3-hour test. Abnormal results on both tests confirms the diagnosis of gestational diabetes. In some pregnant women, blood tests to screen for thyroid disorders (measurement of thyroid-stimulating hormone [TSH]) are done. These women may include those who
Most obstetricians recommend at least one ultrasound examination during each pregnancy, ideally between 16 and 20 weeks, when estimated delivery date (EDD) can still be confirmed fairly accurately and when placental location and fetal anatomy can be evaluated. Estimates of gestational age are based on measurements of fetal head circumference, biparietal diameter, abdominal circumference, and femur length. Measurement of fetal crown-rump length during the 1st trimester is particularly accurate in predicting EDD: to within about 5 days when measurements are made at < 12 weeks gestation and to within about 7 days at 12 to 15 weeks. Ultrasonography during the 3rd trimester is accurate for predicting EDD to within about 2 to 3 weeks.
If ultrasonography is needed during the 1st trimester (eg, to evaluate pain, bleeding, or viability of pregnancy), use of an endovaginal transducer maximizes diagnostic accuracy; evidence of an intrauterine pregnancy (gestational sac or fetal pole) can be seen as early as 4 to 5 weeks and is seen at 7 to 8 weeks in > 95% of cases. With real-time ultrasonography, fetal movements and heart motion can be directly observed as early as 5 to 6 weeks. Conventional x-rays can induce spontaneous abortion or congenital malformations, particularly during early pregnancy. Risk is remote (up to about 1/million) with each x-ray of an extremity or of the neck, head, or chest if the uterus is shielded. Risk is higher with abdominal, pelvic, and lower back x-rays. Thus, for all women of childbearing age, an imaging test with less ionizing radiation (eg, ultrasonography) should be substituted when possible, or if x-rays are needed, the uterus should be shielded (because pregnancy is possible). Medically necessary x-rays or other imaging should not be postponed because of pregnancy. However, elective x-rays are postponed until after pregnancy. Problems identified during evaluation are managed. What to avoid, what to expect, and when to obtain further evaluation are explained. Couples are encouraged to attend childbirth classes.  To provide nutrition for the fetus, most women require about 250 kcal extra daily; most calories should come from protein. If maternal weight gain is excessive (> 1.4 kg/month during the early months) or inadequate (< 0.9 kg/month), diet must be modified further. Weight-loss dieting during pregnancy is not recommended, even for morbidly obese women. Most pregnant women need a daily oral iron supplement of ferrous sulfate 300 mg or ferrous gluconate 450 mg, which may be better tolerated. Woman with anemia should take the supplements twice a day. All women should be given oral prenatal vitamins that contain folate 400 mcg (0.4 mg), taken once a day; folate reduces risk of neural tube defects. For women who have had a fetus or infant with a neural tube defect, the recommended daily dose is 4000 mcg (4 mg). Exercise during pregnancy has minimal risks and has demonstrated benefits for most pregnant women, including maintenance or improvement of physical fitness, control of gestational weight gain, reduction in low back pain, and possibly a reduction in risk of developing gestational diabetes or preeclampsia. Moderate exercise is not a direct cause of any adverse pregnancy outcome; however, pregnant women may be at greater risk of injuries to joints, falling, and abdominal trauma. Abdominal trauma can result in abruptio placentae, which can lead to fetal morbidity or death. Sexual intercourse can be continued throughout pregnancy unless vaginal bleeding, pain, leakage of amniotic fluid, or uterine contractions occur. The safest time to travel during pregnancy is between 14 and 28 weeks, but there is no absolute contraindication to travel at any time during pregnancy. Pregnant women should wear seat belts regardless of gestational age and type of vehicle. Travel on airplanes is safe until 36 weeks gestation. The primary reason for this restriction is the risk of labor and delivery in an unfamiliar environment. During any kind of travel, pregnant women should stretch and straighten their legs and ankles periodically to prevent venous stasis and the possibility of thrombosis. For example, on long flights, they should walk or stretch every 2 to 3 hours. In some cases, the clinician may recommend thromboprophylaxis for prolonged travel. The hepatitis B vaccine can be safely used if indicated, and the influenza vaccine is strongly recommended for women who are pregnant or postpartum during influenza season. Booster immunization for diphtheria, tetanus, and pertussis (Tdap) between 27 and 36 weeks gestation or postpartum is recommended, even if women have been fully vaccinated. Because pregnant women with Rh-negative blood are at risk of developing Rh(D) antibodies, they are given Rh(D) immune globulin 300 mcg IM in any of the following situations:
Pregnant women should not use alcohol and tobacco and should avoid exposure to secondhand smoke. They should also avoid the following:
Women should be advised to seek evaluation for unusual headaches, visual disturbances, pelvic pain or cramping, vaginal bleeding, rupture of membranes, extreme swelling of the hands or face, diminished urine volume, any prolonged illness or infection, or persistent symptoms of labor. Multiparous women with a history of rapid labor should notify the physician at the first symptom of labor. Click here for Patient Education |
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation
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