Standards Of Prenatal Care

Standards Of Prenatal Care

The prenatal period involves complex physiologic changes and emotional adjustments for the pregnant woman. Pregnancy provides an opportunity for preventive health care, maintenance, and education. Although the primary goal of antepartum care is to ensure a healthy mother and baby, a goal of equal importance is to promote an optimal physical and emotional experience for the family.

Prenatal care, therefore, becomes a screening process to differentiate those babies and mothers at jeopardy (high risk) from those in little danger (low risk). To be effective, such an assessment system must be based on a thorough and uncompromising search for those factors that may endanger the pregnancy. Obviously, the participation of the woman in prenatal care is essential in identifying and treating problems that may threaten her or her fetus.

The primary health care provider for the pregnant woman is an ideal position to assess not only the physiologic process but also

1. the way in which the patient is adapting to the pregnancy

2. the supports and resources available to her, and

3. the lifestyle and personal belief system subscribed to by the woman and her family

Becker (1982) has developed a prenatal assessment guide that can assist health care providers in gathering a more comprehensive data base from which care specific to the needs of the individual patient can be planned and implemented. This prenatal assessment guide consists of three parts (table 1).

1.The first deals with aspects of physical and physiologic adaptation to pregnancy.

2.The second focuses on aspects of the woman’s personal belief system and lifestyle that may affect her health and the health of the fetus.

3.The third aims to identify the support systems and resources available to the patient that may influence the course and outcome of her pregnancy.

Table 1

Prenatal Assessment Guide

I.	Aspects of Adaptation
1.	Age
2.	Initial response to this pregnancy
3.	Planned or Unplanned pregnancy
4.	Feelings about this pregnancy
5.	Desired family size
6.	Perception of pregnancy affecting present activities and responsibilities
7.	Perception of parenthood affecting future activities and plans
8.	Current developmental tasks of pregnancy: how coping with pregnancy: fantasies about pregnancy; changes in mood and effect on others
9.	Sexual functioning during pregnancy: changes in; feelings about and / or problems with
10.	Nature of verbal interest expressed about self and fetus
11.	Preparation for prenatal classes; place of delivery; care for other children in mother’s absence; care for new sibling
12.	Menstrual history problems with; last normal menstrual period; expected date of confinement
13.	Height and prepregnancy weight
14.	Obstetric status: course, abdominal assessment, quickening, fetal heart sound, blood pressure, urinalysis, weight and pattern of gain, signs of any major complications of pregnancy
15.	Medical history: illness (date)- treatment, outcome, surgery: childhood diseases; current immunization status; allergies; venereal disease; emotional problems
16.	Family medical history: illness, emotional problems, genetic defects (both sides of family)
17.	Loss of significant other in past year
18.	Food intolerance (lactose, nausea/vomiting); food cravings; pica
19.	Iron, vitamin, and / or mineral dietary supplements used
20.	Elimination patterns: changes / problems with remedies used
21.	Pattern of rest, sleep: difficulties with; remedies used
II.	Aspects of Personal Belief System and Lifestyle
1.	Date first sought prenatal care this pregnancy and in prior pregnancies
2.	Reasons for seeking and receiving prenatal care
3.	Beliefs about pregnancy and childbirth; cultural beliefs subscribed to with regard to childbearing (antepartum, intrapartum, postpartum)
4.	Racial-ethnic group
5.	Beliefs about role of father during pregnancy and labour, and role in child care
6.	Perception of needs of fetus
7.	Perception of needs infant and proposed methods to meet those needs
8.	Contraceptive history: methods used; failures and / or problems with: knowledge of alternate methods; willingness to use
9.	Patterns of use of tobacco, alcohol, prescription and nonprescription drugs, illegal drugs; perception of effects of these substances on health of self and fetus
10.	Patterns of nutrient intake: food dislike; history of / method (s) of dieting
11.	Planned method of infant feeding; why chosen
12.	Occupation: Present, former, hours of duty per day, work requirements, hazards, amenities, plans regarding current occupation
13.	Recreational activities: Plans to continue with; use of seat belt in car; pets in home
14.	Community activities
15.	Perception of health care personnel and agencies; prior experiences with
16.	Date of last physical examination including breast examination, Pap smear, chest x-ray, and dental checkup
17.	Breast self examination; done regularly?; if not, interest in learning about?
III.	Aspects of Support
1.	Address: How long there, housing accommodations, phone, plans to move (if so, when where to, why?)
2.	Level of education and future plans regarding education
3.	Religious
4.	Marital status; how long married
5.	Father of baby: age, occupation, educational level, racial-ethnic Group, religious preference
6.	Family composition; household members
7.	Communication patterns with significant others
8.	Communication patterns with health personnel
9.	Perception of Support system (mate, family, friends, community agencies ): how available? How willing to use?
10.	Perception of meaning of this pregnancy to significant others; mate’s response to news of pregnancy
11.	Type of prenatal service receiving; perception of adequacy of available transportation to receive medical care
12.	Social service community agencies involved with: how long? Name of contact person?
13.	Self concept and perceived ability to cope with life situations
14.	Body image: pregnancy; currently; response to physiologic changes of pregnancy
15.	Mate’s response to body changes in pregnancy
16.	Feelings about parenting that woman received as a child; history of separation from mother- what age?
17.	Prior experiences with infants; knowledge of infant care
18.	Feelings about previous pregnancies, labour and puerperium and mothering skills
19.	Knowledge of reproduction, labour and delivery, and puerperium

From Becker CH: Comprehensive assessment of the healthy gravida Nurs 11:375, 1982.

Diagnosis Of Pregnancy

Of fundamental importance is establishment of the diagnosis of pregnancy. If this is confirmed by correlation of historical information, physical examination, and laboratory tests, the estimation of gestational age and estimation of gestational age and estimated date of confinement at this early visit will minimize confusion as the pregnancy continues.

There are many presumptive signs of pregnancy. The most frequent is amenorrhea, which is often the first evidence to the patient of possible conception. Some patients may not be aware of pregnancy until other symptoms appear. These include:

¨ nausea

¨ vomiting

¨ breast fullness

¨ urinary frequency

¨ constipation

¨ fatigue and

¨ enlarging abdomen.

Certain signs of pregnancy are highly suggestive of the diagnosis. These include:

¨ uterine enlargement, softening of the uterine isthmus (Hegar’s sign) and

¨ vaginal and cervical cyanosis (Chadwick’s sign).

Also, a positive laboratory test for human chorionic gonadotropin (h C G) is indicative of pregnancy (Brunel, 1980). Estimation of gestational age by uterine size is one of the most important elements of the first examination. The detection of fetal heart tones at about 10 to 12 weeks of gestation is possible with an ultrasonic Doppler.

The estimated date of confinement can be calculated by Nagele’s rule: Add 7 days to the first day of the last menstrual period and subtract 3 months.

Initial Prenatal Care

Once there is a confirmed diagnosis of pregnancy, an initial visit should be scheduled as soon as it is feasible. During the initial interview with the woman, careful attention to detail is necessary. This first visit is to assess risk and establish a plan of care, and should include:

1. A careful screening history.

2. A general to specific physical examination designed to exclude risk factors.

3. Routine laboratory screening (Table 2).

4. Individually indicated maternal laboratory evaluation (Table 3).

5. Careful fetal assessment.

6. Specialized studies to ascertain fetal well-being and / or fetal maturity as individual indicated.

Patient biographic data -

¨ age,

¨ race,

¨ religion,

¨ marital status, and

¨ economic factors - must be carefully considered at this time.

Historical data should include:

¨ obstetric history (gravidity, parity, and details of previous pregnancies), menstrual history and contraceptive history.

¨ A complete medical history must be obtained to screen for medical problems that may cause complications or be aggravated by the pregnancy. These include:

¨ diabetes mellitus,

¨ hypertension,

¨ thyroid disorders,

¨ cardiac disease, and

¨ seizure disorders.

Items of significance from the family history are

¨ multiple gestation,

¨ diabetes mellitus,

¨ hypertension

¨ preeclampsia and eclampsia,

¨ bleeding disorders, and

¨ hereditary illnesses (e.g., hemophilia, Down’s syndrome) During the physical examination, attention should be directed to specific organ systems as a positive history is elicited.

A general examination should especially evaluate

¨ the blood pressure,

¨ weight,

¨ height,

¨ optic fundi,

¨ thyroid,

¨ lungs,

¨ heart,

¨ abdomen, and

¨ extremities.

Table2

General Laboratory Examination

Tests	Initial Visit	26-30 Weeks	36 Weeks	Findings that Signal Further Assessment
Blood Tests 1. Complete Blood Count (CBC) a) Hemoglobin (Hgb) or b) Hematocrit (Hct) c) White blood cell count (WBC) d) Differential smear (Diff)	X X X	X	X	Hgb < 10 g/dl^d Hct 32 percent or less 15,000 mmm or more Cellular abnormalities and / or decreased platelets
2. Blood Group	X
3. Rh Factor	X			Mother: Rh-negative Mate: Rh-positive or unknown
4. Antibody Screen	X			A titer defined by the laboratory
5. Serology for Syphilis	X		Repeat	Positive
6. Rubella Screen (titer)	X			A titer of 1:8 or less, or a significant rise in titer
7. Two-Hour Postprandial Blood Sugar	Obtain	X	X	145 mg/dl or more
8. Hepatitis B	X		Repeat	Positive
Urine Tests 1. Urine Bacteria Screen	X	X		Positive
2. Urine Glucose and Protein	At Each Visit			Protein 1+ or more Glucose 1= or more
Cervical Tests 1. Papanicolaou smear (Pap smear)	X			Positive
2. Culture for gonorrhea	X		Repeat	Positive

Table 3

Specific Laboratory Examinations

Tests	Initial Visit	24 28 Weeks	36 Weeks	Findings that Signal Further Assessment
Blood Tests Anti body screen (Rh- negative woman	X	X	X	Significant, as defined by the local laboratory
Oral glucose tolerance test (OGTT)		24-28 wks X		plasma threshold 140 mg/dl
Human Immunovirus (HIV)	offer screening to at-risk women at initial visit			Positive
Maternal serum-Alpha Fetal Protein	initial visit counsel; offer test to be done at 15 - 20 weeks			> 2.0 MoMs
Sickle Cell Screen	X			Positive for trait or anemia
Tay-Sachs Screen	X			Carrier
Cervical test Herpesvirus hominis, Type 2	When physical findings indicate at any prenatal visit		X	Positive
Skin Test Tuberculosis	X			Positive