Chapter 9 Antepartum Nursing Assessment

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I’m 16—just got my license—so it was weird telling my friends that my mom is pregnant. I was embarrassed
(and a little jealous) at first but now I kind of like the idea of having a baby sister. Mom had an
amniocentesis because she is 37, so we know it’s a girl. My mom has been great about including me and
telling me what is going on. I’ve gone to a couple of her prenatal appointments so I got to hear the
heartbeat and I saw the baby moving on ultrasound. I’m surprised by how interesting I am finding
everything. Don’t laugh, but I think I might like to be a nurse-midwife someday.
—Krista, 16

Learning Outcomes
9.1 Summarize the essential components of a prenatal history.
9.2 Define common obstetric terminology found in the history of maternity clients.
9.3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a
pregnant ​woman.
9.4 Calculate the estimated date of birth using the common methods.
9.5 Describe the essential measurements that can be determined by clinical pelvimetry.
9.6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the
prenatal client.
9.7 Relate the danger signs of pregnancy to their possible causes.
9.8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and
the nursing care of the prenatal client.

During the antepartum period, the role of the nurse is determined by academic
preparation, clinical expertise, and professional credentials. The RN may complete
many areas of prenatal assessment. Advanced practice nurses such as certified
nurse-midwives (CNMs) and nurse practitioners are able to perform complete
antepartum assessments. This chapter focuses on the prenatal assessments
completed initially and at subsequent visits to provide optimum care for the
childbearing family.

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 Healthy People 2020
(MICH-1) Reduce the rate of fetal and infant deaths

(MICH-5) Reduce the rate of maternal mortality

(MICH-6) Reduce maternal illness and complications due to pregnancy (complications during
hospitalized labor and delivery)

(MICH-10) Increase the proportion of pregnant women who receive early and adequate prenatal care

Initial Client History

The course of a pregnancy depends on a number of factors, including the woman’s prepregnancy health, presence of
disease/illness states, family history, emotional status, and past health care. A thorough history helps determine the
status of a woman’s prepregnancy health.

Definition of Terms
The following terms are used in recording the history of maternity clients:

Antepartum : time between conception and the onset of labor; describes the period during which a woman is
pregnant; used interchangeably with prenatal
Intrapartum : time from the onset of true labor until the birth of the baby and placenta
Postpartum : time from the delivery of the placenta and membranes until the woman’s body returns to a
nonpregnant condition; typically about 6 weeks
Gestation : the number of weeks of pregnancy since the first day of the last menstrual period
Abortion : birth that occurs before the end of 20 weeks’ gestation or the birth of a fetus-newborn who weighs less
than 500 g (Cunningham et al., 2014). Abortion is abbreviated as ab. An abortion may occur spontaneously or it may
be induced by medical or surgical means. If induced, it is often termed a therapeutic abortion.
Stillbirth : a baby born dead after 20 weeks’ gestation
Term : a word that was formerly used to identify the normal duration of pregnancy. The stand-alone use of this
word is now discouraged because it represents such a wide range of time and related risk (Spong, 2013). The
American College of Obstetrics and Gynecology (ACOG, 2013a) recommends that the following definitions be used:
Late preterm : births that occur between 34 0/7 through 36 6/7 weeks’ gestation (ACOG, 2013c).
Early term : births occurring between 37 weeks 0 days and 38 weeks 6 days
Full term : births occurring between 39 weeks 0 days and 40 weeks 6 days
Late term : births occurring between 41 weeks 0 days through 41 weeks 6 days
Postterm : births occurring after 42 weeks
Preterm labor : labor that occurs after 20 weeks’ gestation but before completion of 36 weeks’ gestation
Postterm labor : labor that occurs after 42 weeks’ gestation
Gravida : any pregnancy, regardless of duration, including present pregnancy. Gravida is often abbreviated as G.
Nulligravida : a woman who has never been pregnant
Primigravida : a woman who is pregnant for the first time
Multigravida : a woman who is in her second or any subsequent pregnancy
Para : birth after 20 weeks’ gestation regardless of whether the baby is born alive or dead. Para is often
abbreviated as P.
Nullipara : a woman who has had no births at more than 20 weeks’ gestation
Primipara : a woman who has had one birth at more than 20 weeks’ gestation regardless of whether the baby
was born alive or dead
Multipara : a woman who has had two or more births at more than 20 weeks’ gestation

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 The terms gravida and para refer to pregnancies, not to the fetus. Thus, traditionally, twins, triplets, and other multiple
fetuses are counted as one pregnancy and one birth. This approach is confusing, however, because it fails to identify
the number of children that a woman might have. To provide comprehensive data, a more detailed approach is used in
some settings. A useful acronym for remembering the system is TPAL (King, Brucker, Kriebs, et al., 2015).

T: number of early, full, or late term births the woman has experienced (number of babies born at the 37 0/7 weeks’
gestation or beyond)

P: number of preterm births (births after 20 weeks’ gestation but before 37 0/7weeks’ gestation, whether living or ​‐
stillborn)

A: number of pregnancies ending in either spontaneous or therapeutic abortion (before 20 weeks’ gestation)

L: number of currently living children to whom the woman has given birth

The following examples delineate the differences between the two systems.

1. Jean Sanchez has one child born at 39 weeks’ gestation and became pregnant for a second time. The second
pregnancy ended in a miscarriage at 15 weeks’ gestation. Using the traditional approach her obstetric history
would be recorded as “gravida 2 para 1 ab 1.” Using the detailed approach, her obstetric history would be
recorded as “gravida 2 para 1011.”
2. Tracy Hopkins is pregnant for the fourth time. At home she has a child who was born at full term. Her second
pregnancy ended at 10 weeks’ gestation. She then gave birth to twins at 35 weeks. Using the traditional approach
her obstetric history would be recorded as gravida 4 para 2 ab 1. Using the detailed approach her obstetric
history would be recorded as “gravida 4 para 1113.”

To avoid confusion, it is best for practicing nurses to clarify the recording system used at their facilities.

Clinical Tip

In general, it is best to avoid an initial discussion of a woman’s gravida and para status in front of her partner. It
is possible that the woman had a previous pregnancy that she has not mentioned to her partner, and revealing
the information could violate her right to privacy.

Client Profile
The history is essentially a screening tool to identify factors that may place the mother or fetus at risk during the
pregnancy. The following information is obtained for each pregnant woman at the first prenatal assessment:

1. Current pregnancy
First day of last normal menstrual period (LMP) (Is she sure of the dates or uncertain? Do her cycles normally
occur every 28 days, or do her cycles tend to be longer?)
Presence of cramping, bleeding, or spotting since LMP
Woman’s opinion about the time when conception occurred and when baby is due
Woman’s attitude toward pregnancy (Is this pregnancy planned? Wanted?)
Results of pregnancy tests, if completed
Any discomforts since LMP such as nausea, vomiting, urinary frequency, fatigue, or breast tenderness

2. Past pregnancies
Number of pregnancies
Number of abortions, spontaneous or induced
Number of living children
History of previous pregnancies, length of pregnancy, length of labor and birth, type of birth (vaginal, forceps-
assisted, vacuum-assisted birth, or cesarean), location of birth, type of anesthesia used (if any), woman’s
perception of the experience, and complications (antepartum, intrapartum, and postpartum)
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 Neonatal status of previous children: Apgar scores, birth weights, general development, complications, and
feeding patterns (breast milk, formula, or both). If breastfed, for how long?
Loss of a child (miscarriage, elective or medically indicated abortion, stillbirth, neonatal death, relinquishment,
or death after the neonatal period). Cause of loss? What was the experience like for her? What coping skills
helped? How did her partner, if involved, respond?
Blood type and Rh factor (If Rh negative, was Rh immune globulin received after birth/miscarriage/abortion?
Baby’s blood type)
Prenatal education classes and resources (books, websites); knowledge about pregnancy, childbirth, and
parenting

3. Gynecologic history
Date of last Papanicolaou (Pap) smear; result? Any history of abnormal Pap smear; any follow-up therapy
completed
Previous infections: vaginal, cervical, pelvic inflammatory disease (PID), or sexually transmitted infections
(STIs)
Previous surgery (uterine, ovarian)
Age at menarche
Regularity, frequency, and duration of menstrual flow
History of dysmenorrhea
History of infertility
Sexual history
Contraceptive history (If hormonal method used, did pregnancy occur immediately following cessation of
method? If not, how long after? When was contraception last used?)
Any issues related to infertility or fertility treatments

4. Current medical history

Weight (prepregnancy and current), height, body mass index (BMI) (determine recommended weight gain)
General health, including nutrition (dietary practices such as vegetarianism; lactose intolerance; food
allergies?), regular exercise program (type, frequency, and duration); monthly breast self-examination; eye
examination; date of last dental examination
Any medications presently being taken (including prescription, nonprescription, homeopathic, or herbal
medications) or taken since the onset of pregnancy
Previous or present use of alcohol, tobacco, or caffeine (Ask specifically about the amounts of alcohol,
cigarettes, and caffeine [specify coffee, tea, colas, or chocolate] consumed each day.)
Illicit drug use or abuse (Ask about specific drugs such as cocaine, crack, methamphetamines, and marijuana;
planning cessation?)
Drug allergies and other allergies (Ask about latex allergies or sensitivities.)
Potential teratogenic insults to this pregnancy such as viral infections, medications, x-ray examinations, ​‐
surgery, or cats in the home (possible source of toxoplasmosis)
Presence of chronic disease conditions such as diabetes, hypertension, cardiovascular disease, renal problems,
cancer, or thyroid disorder
Infections or illnesses since LMP (flu, measles)
Record of immunizations (especially rubella); up to date?
Presence of any abnormal signs/symptoms

5. Past medical history

Childhood diseases
Past treatment for any disease condition (Any hospitalizations? Major injuries?)
Surgical procedures
Presence of bleeding disorders or tendencies (Has she received blood transfusions? Will she accept blood
transfusions?)

6. Family medical history

Presence of diabetes, cardiovascular disease, cancer, hypertension, hematologic disorders, tuberculosis,
thyroid disease
Occurrence of multiple births
History of congenital diseases or deformities
Occurrence of cesarean births and cause, if known

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 7. Genetic history (client, father of the child [FOC], and both families)
Birth defects
Recurrent pregnancy loss
Stillbirth
Down syndrome, intellectual disability, developmental delay, chromosomal abnormalities
Ethnic background (Mediterranean descent, Jewish, Asian)
Genetic disorders (cystic fibrosis, sickle cell disease/trait, muscular dystrophy).

8. Religious, spiritual, and cultural history

Does the woman wish to specify a religious preference on her medical record? Does she have any spiritual
beliefs or practices that might influence her health care or that of her child, such as a prohibition against
receiving blood products, dietary considerations, or circumcision rites?
What practices are important for her spiritual well-​being?
Might practices in her culture or that of her partner influence her care or that of her child?

9. Occupational history
Occupation
Physical demands (Does she stand all day, or are there opportunities to sit and elevate her legs? Any heavy ​‐
lifting?)
Exposure to chemicals or other harmful substances
Opportunity for regular meals and breaks for nutritious snacks
Provision for maternity or family leave

10. Birth father’s physical history

Age
Significant health problems
Blood type and Rh factor
Presence of genetic conditions or diseases in him or in his family history

11. Father’s/partner’s social history

Occupation
Educational level; methods by which he or she learns best
Current tobacco use, drug use, and alcohol intake
Thoughts/feelings about the pregnancy

12. Personal history

Age
Relationship status (Married? Birth father involved? Partner’s level of involvement [if partner is not the father
of the child])
Educational level; methods by which she learns best
Race or ethnic group (to identify need for prenatal genetic screening and racially or ethnically related risk
factors)
Housing; stability of living conditions; neighborhood safety; animals in the home
Economic level: ability to pay bills, purchase nutritious food; use of supplemental programs such as WIC
Acceptance of pregnancy, whether intended or ​unintended
Any history of emotional or physical deprivation or abuse of herself or children or any abuse in her current
relationship (Has she been hit, slapped, kicked, or hurt within the past year or since she has been pregnant? Is
she afraid of her partner or anyone else? If yes, of whom is she afraid? [Note: Ask these questions when the
woman is alone.])
History of emotional/mental health problems (depression in general, postpartum depression, anxiety, bipolar
disorder)
Support systems
Personal preferences about the birth (expectations of both the woman and her partner, presence of others,
and so on)
Plans for care of newborn following birth; plans for circumcision if the baby is male.
Feeding preference for the baby (Breast milk or formula?)

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 Obtaining Data
A questionnaire is often used to obtain information. Some clinics and offices send the form via e-mail or regular mail, or
post the form on their website for downloading, so the woman can complete it prior to her first prenatal visit; others
prefer that it be done in person. In either case, the woman should complete the questionnaire in a quiet place with a
minimum of distractions. The nurse can get further information in an interview, which allows the pregnant woman to
clarify her responses to questions and gives the nurse and client the opportunity to develop rapport.

Safety Alert!

Because some medications may pose a risk to the fetus if taken during pregnancy, it is crucial to develop a list
of all the medications the pregnant woman is currently taking as well as those she had been taking before she
learned she was pregnant. This list should be given to the client’s primary healthcare provider. (See discussion
of classification system for medications taken during pregnancy in Chapter 10 .)

The expectant father or partner can be encouraged to attend the prenatal examinations. The partner is often able to
contribute to the history and may use the opportunity to ask questions or express concerns that are important to him or
her.

Prenatal Risk-Factor Screening

Risk factors are any findings that suggest the pregnancy may have a negative outcome for either the woman or her
unborn child. Screening for risk factors is an important part of the prenatal assessment. Many risk factors can be
identified during the initial assessment; others may be detected during subsequent prenatal visits. It is important to
identify high-risk pregnancies early so that appropriate interventions can be started promptly. Not all risk factors
threaten a pregnancy equally; thus many agencies use a scoring sheet to determine the degree of risk. Information
must be updated throughout pregnancy as necessary. Any pregnancy may begin as low risk and change to high risk
because of complications.

Clinical Reasoning Hot Tub Use in Pregnancy

Karen Blade, a 23-year-old woman, G1P0, is 10 weeks’ pregnant when she sees you for her first prenatal
examination. She has been experiencing some mild nausea and fatigue but otherwise is feeling well. She asks
you about continuing with her routine exercises (walking 3 miles a day and lifting light weights). She also asks
about using the heated pool and a hot tub. What should you tell her?
Table 9–1 identifies the major risk factors currently recognized. The table also identifies maternal and fetal or
newborn implications if the risk is present in the pregnancy.

Table 9–1 Prenatal High-Risk Factors

Factor Maternal Implications Fetal or Neonatal Implications

Social and Personal

Low income level and/or low educational level Insufficient antenatal care or late antenatal Low birth weight
care
Prematurity
↑ risk preterm birth
Intrauterine growth restriction (IUGR)/small for
Poor nutrition gestational age (SGA)

↑ risk preeclampsia

Poor diet Inadequate nutrition Fetal malnutrition

↑ risk preterm birth IUGR/SGA

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 ↑ risk anemia Prematurity

↑ risk preeclampsia

Living at high altitude ↑ hemoglobin Prematurity

IUGR

↑ hemoglobin (polycythemia)

Multiparity greater than 3 ↑ risk antepartum or postpartum Anemia

hemorrhage

Fetal death

Weight less than 45.5 kg (100 lb) Poor nutrition IUGR/SGA

Cephalopelvic disproportion Hypoxia associated with difficult labor and birth

Prolonged labor

Weight greater than 91 kg (200 lb) ↑ risk hypertension ↓ fetal nutrition

↑ risk cephalopelvic disproportion ↑ risk macrosomia

↑ risk diabetes

Age less than 16 years Poor nutrition Low birth weight

Insufficient antenatal care ↑ fetal demise

↑ risk preeclampsia

↑ risk cephalopelvic disproportion

Age older than 35 ↑ risk preeclampsia ↑ risk congenital anomalies

↑ risk cesarean birth ↑ chromosomal abnormalities

Smoking one pack/day or more ↑ risk hypertension ↓ placental perfusion

→ ↓ O2 and nutrients available

↑ risk cancer Low birth weight

IUGR/SGA

Preterm birth

Use of addictive drugs ↑ risk poor nutrition ↑ risk congenital anomalies

↑ risk infection with IV drugs ↑ risk abruptio placentae

↑ risk HIV, hepatitis C ↑ risk low birth weight

Neonatal withdrawal

Lower serum bilirubin

Excessive alcohol consumption ↑ risk poor nutrition ↑ risk fetal alcohol syndrome

Possible hepatic effects with long-term ​‐

consumption

Preexisting Medical Disorders

Diabetes mellitus ↑ risk preeclampsia, hypertension Low birth weight

Episodes of hypoglycemia and Macrosomia

hyperglycemia

↑ risk cesarean birth Neonatal hypoglycemia

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 ↑ risk congenital anomalies

↑ risk respiratory distress syndrome

Cardiac disease Cardiac decompensation ↑ risk fetal demise

Further strain on mother’s body ↑ prenatal mortality

↑ maternal death rate

Anemia: hemoglobin less than 11 g/dL or less than Iron deficiency anemia Fetal death
32% hematocrit
Low energy level Prematurity

Decreased oxygen-carrying capacity Low birth weight

Hypertension ↑ vasospasm ↓ placental perfusion

↑ risk central nervous system irritability → low birth weight

→ convulsions Preterm birth

↑ risk cerebrovascular accident

↑ risk renal damage

Thyroid disorder ↑ infertility ↑ spontaneous abortion

Hypothyroidism ↓ basal metabolic rate, goiter, myxedema ↑ risk congenital goiter

↑ risk miscarriage, preterm labor/birth ↑ risk IUGR/SGA

↑ risk preeclampsia ↑ risk stillbirth

Hyperthyroidism ↓ risk postpartum hemorrhage Mental retardation →

↑ risk preeclampsia cretinism

Danger of thyroid storm ↑ incidence congenital anomalies

↑ incidence preterm birth, IUGR/SGA

↑ risk neonatal hyperthyroidism

↑ tendency to thyrotoxicosis

Renal disease (moderate to severe) ↑ risk renal failure ↑ risk IUGR/SGA

↑ risk preterm birth

Diethylstilbestrol (DES) exposure ↑ infertility, spontaneous abortion

↑ cervical insufficiency ↑ risk preterm birth

Obstetric Considerations

Previous Pregnancy

Stillborn ↑ emotional or psychologic distress ↑ risk IUGR/SGA

↑ risk preterm birth

Recurrent abortion ↑ emotional or psychologic distress ↑ risk abortion

Cesarean birth ↑ possibility repeat cesarean birth ↑ risk preterm birth

↑ risk respiratory distress

Rh or blood group sensitization ↑ risk erythroblastosis fetalis

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 Hydrops fetalis

Neonatal anemia

Kernicterus

Hypoglycemia

Large baby ↑ risk cesarean birth Birth injury

↑ risk gestational diabetes Hypoglycemia

Current Pregnancy

Rubella (first trimester) Congenital heart disease

Cataracts

Nerve deafness

Bone lesions

Prolonged virus shedding

Toxoplasmosis Retinochoroiditis

Convulsions, coma, microcephaly

Rubella (second trimester) Hepatitis

Thrombocytopenia

Cytomegalovirus IUGR

Encephalopathy

Herpesvirus type 2 Severe discomfort Neonatal herpesvirus type 2

Concern about possibility of cesarean birth, 2% hepatitis with jaundice

fetal infection
Neurologic abnormalities

Syphilis ↑ incidence abortion ↑ fetal demise

Congenital syphilis

HIV positive Candidal infections Transmission of HIV

Wasting syndrome

Concurrent STIs such as herpes

Postpartum hemorrhage, poor wound

healing

Abruptio placentae and placenta previa ↑ risk hemorrhage Fetal or neonatal anemia

Bed rest Intrauterine hemorrhage

Extended hospitalization ↑ fetal demise

Preeclampsia or eclampsia See hypertension ↑ placental perfusion

→ low birth weight

Multiple gestation ↑ risk postpartum hemorrhage ↑ risk preterm labor/birth

↑ risk preterm labor ↑ risk stillbirth

↑ risk gestational diabetes mellitus ↑ risk fetal demise, IUGR/SGA

↑ risk placenta previa ↑ risk malpresentation

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 ↑ risk preeclampsia ↑ risk stillbirth

Elevated hematocrit Increased viscosity of blood Fetal death rate 5 times normal rate

Greater than 41% (White)

Greater than 38% (Black)

Spontaneous premature rupture of ​membranes ↑ uterine infection Preterm birth

Fetal demise

Note: This table is not inclusive of all potential outcomes.

Initial Prenatal Assessment

The initial prenatal assessment focuses on the woman holistically by considering physical, cultural, and psychosocial
factors that influence her health. The establishment of the nurse-client relationship is a chance to develop an
atmosphere conducive to interviewing, support, and education. Because many women are excited and anxious at the
first antepartum visit, the initial psychosocial-cultural assessment is general.

As part of the initial psychosocial-cultural assessment, discuss with the woman any religious or spiritual, cultural, or
socioeconomic factors that influence the woman’s expectations of the childbearing experience. It is especially helpful to
be familiar with common practices of the members of various religious and cultural groups who reside in the
community.

Women With Special Needs Assessing Care Needs During

Pregnancy
During the initial assessment, the woman with a disability should be questioned to determine her current level of
functioning and the degree of assistance she normally requires in her everyday routine. This assists the
healthcare team in planning care and interventions that may be needed. Care needs may change during
pregnancy and warrant ongoing assessments of the woman’s level of functioning.
After obtaining the history, prepare the woman for the physical examination. The physical examination begins with
assessment of vital signs; then the woman’s body is examined. The pelvic examination is performed last.

Before the examination the woman should provide a clean urine specimen for screening. When her bladder is empty,
the woman is more comfortable during the pelvic examination and the examiner can palpate the pelvic organs more
easily. After the woman empties her bladder, the nurse should ask her to disrobe and give her a gown and sheet or
some other protective covering.

Professionalism in Practice Physical Exams and Scope of Practice

Increasing numbers of nurses, such as CNMs, nurse practitioners, and other nurses in advanced practice, are
educationally prepared to perform complete physical examinations. The nurse who is not an advanced
practitioner assesses the woman’s vital signs, explains the procedures to allay apprehension, positions her for
examination, and assists the examiner as necessary. Each nurse is responsible for operating at expected
professional standards within his or her skill level, educational preparation, and knowledge base.
Thoroughness and a systematic procedure are the most important considerations when performing the physical portion
of an antepartum examination. See Assessment Guide: Initial Prenatal Assessment. To promote completeness, the
assessment guide is organized in three columns that address the areas to be assessed (and normal findings), the
variations or alterations that may be observed, and nursing responses to the data. Certain organs and systems are
assessed concurrently with others during the physical portion of the examination.

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 Clinical Tip

Gloves are worn for procedures that involve contact with body fluids such as drawing blood for laboratory work,
handling urine specimens, and conducting pelvic examinations. Because of the increased incidence of latex
allergies, it is becoming more common for nonlatex gloves to be used. It is important to inquire about latex
allergies with any client before beginning an examination.

Nursing interventions based on assessment of the normal physical and psychosocial changes of pregnancy, evaluation
of the cultural influences associated with pregnancy, and mutually defined client teaching and counseling needs are
discussed further in Chapter 10 .

Assessment Guide Initial Prenatal Assessment

Physical Assessment/Normal Findings Alterations and Possible Causes* Nursing Responses to Data†

Vital Signs

Blood pressure (BP): Less than or equal High BP (essential hypertension; renal BP of 120–139/80–89 is considered prehypertensive.
to 120/80 mmHg. disease; pregestational hypertension,
BP greater than 140/90 requires immediate
apprehension; preeclampsia if initial
consideration; establish woman’s BP; refer to healthcare
assessment not done until after 20
provider if necessary. Assess woman’s knowledge about
weeks’ gestation)
high BP; counsel on self-care and medical management.

Pulse: 60–100 beats/min; rate may Increased pulse rate (excitement or Count for 1 full minute; note irregularities.
increase 10 beats/min during pregnancy anxiety, dehydration, cardiac disorders)
Evaluate temperature, increase fluids.

Respirations: 12–20 breaths/min (or pulse Marked tachypnea or abnormal patterns Assess for respiratory disease.
rate divided by 4); pregnancy may induce a
degree of hyperventilation; thoracic
breathing predominant

Temperature: 97°–99.6°F (36.2°–37.6°C) Elevated temperature (infection) Assess for infection process or disease state if
temperature is elevated; refer to healthcare provider.

Weight

Amount of weight gain depends on body Weight less than 45 kg (100 lb) or Evaluate need for nutritional counseling; obtain
build Evaluate need for nutritional counseling; information on eating habits, cooking practices, food
greater than 91 kg (200 lb); rapid, regularly eaten, food allergies, income limitations, need
Underweight: 28–40 lb (12.5–18.0 kg)
obtain information on eating habits, for food supplements, and pica and other abnormal food
Normal weight: 25–35 lb (11.5–16.0 kg) sudden weight gain (preeclampsia) habits. Note initial weight to establish baseline for weight
gain throughout pregnancy. Determine body mass index
Overweight: 15–25 lb (7.0–11.5 kg)
(BMI) and recommend amount of weight gain for
Obese: 11–20 lb (5.0–9.1 kg) pregnancy.

Skin

Color: Consistent with racial background; Pallor (anemia); bronze, yellow (hepatic The following tests should be performed: complete blood
pink nail beds disease; other causes of jaundice) count (CBC), bilirubin level, urinalysis, and blood urea
nitrogen (BUN). If abnormal, refer to healthcare provider.
Bluish, reddish, mottled; dusky
appearance or pallor of palms and
nailbeds in dark-skinned women
(anemia)

Condition: Absence of edema (slight Edema (preeclampsia, normal Counsel on relief measures for slight edema. Initiate
edema of lower extremities is normal ​‐ pregnancy changes); rashes, dermatitis preeclampsia assessment; refer to healthcare provider.
during pregnancy) (allergic response)

Lesions: Absence of lesions Ulceration (varicose veins, decreased Further assess circulatory status; refer to healthcare
circulation) provider if lesion is severe.

Spider nevi common in pregnancy Petechiae, multiple bruises, ecchymosis Evaluate for bleeding or clotting disorder. Provide

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 Refer to healthcare provider.

Moles

Pigmentation: Pigmentation changes of Change in size or color (carcinoma) Assure woman that these are normal manifestations of
pregnancy include linea nigra, striae pregnancy and explain the physiologic basis for the
gravidarum, melasma changes.

Cafe-au-lait spots Six or more (Albright syndrome or ​‐ Consult with healthcare provider.
neurofibromatosis)

Nose

Character of mucosa: Redder than oral Olfactory loss (first cranial nerve deficit) Counsel woman about possible relief measures for nasal
mucosa; in pregnancy nasal mucosa is stuffiness and nosebleeds (epistaxis); refer to healthcare
edematous in response to increased provider for olfactory loss.
estrogen, resulting in nasal stuffiness
(rhinitis of pregnancy) and nosebleeds

Mouth

May note hypertrophy of gingival tissue Edema, inflammation (infection); pale in Assess hematocrit for anemia; counsel regarding dental
because of estrogen color (anemia) hygiene habits. Refer to healthcare provider or dentist if
necessary. Routine dental care appropriate during
pregnancy.

Neck

Nodes: Small, mobile, nontender nodes Tender, hard, fixed, or prominent nodes Examine for local infection; refer to healthcare provider.
(infection, carcinoma)

Thyroid: Small, smooth, lateral lobes Enlargement or nodule tenderness Test to perform: thyroid-stimulating hormone (TSH).
palpable on either side of trachea; slight (hyperthyroidism) Listen over thyroid for bruits, which may indicate
hyperplasia by third month of pregnancy hyperthyroidism. Question woman about dietary habits
(iodine intake). Ascertain history of thyroid problems;
refer to healthcare provider.

Chest and Lungs

Chest: Symmetric, elliptic, smaller Increased AP diameter, funnel chest, Evaluate for emphysema, asthma, pulmonary disease.
anteroposterior (AP) than transverse pigeon chest (emphysema, asthma,
diameter pulmonary disease)

Ribs: Slope downward from nipple line More horizontal (pulmonary disease) Evaluate for pulmonary disease.
angular bumps rachitic rosary (vitamin C
Evaluate for fractures.
deficiency)

Inspection and palpation: No retraction ICS retractions with inspirations, bulging Do thorough initial assessment. Refer to healthcare
or bulging of intercostal spaces (ICS) during with expiration; unequal expansion provider.
inspiration or expiration; symmetric (respiratory disease)
expansion.

Tactile fremitus Tachypnea, hyperpnea (respiratory Refer to healthcare provider.

disease)

Percussion: Bilateral symmetry in tone Flatness of percussion, which may be Evaluate for pleural effusions, consolidations, or tumor.
affected by chest wall thickness

Low-pitched resonance of moderate High diaphragm (atelectasis or Refer to healthcare provider.

intensity paralysis), pleural effusion

Auscultation: Upper lobes: Abnormal if heard over any other area of Refer to healthcare provider.
bronchovesicular sounds above sternum chest
and scapulas; equal expiratory and
inspiratory phases

Remainder of chest: vesicular breath Rales, rhonchi, wheezes; pleural friction Refer to healthcare provider.
sounds heard; inspiratory phase longer rub; absence of breath sounds;
(3:1) bronchophony, egophony, whispered
pectoriloquy

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 Breasts

Supple: Symmetric in size and contour; “Pigskin” or orange-peel appearance, Encourage monthly self-examination; instruct woman
darker pigmentation of nipple and areola; nipple retractions, swelling, hardness how to examine her own breasts.
may have supernumerary nipples, usually (carcinoma); redness, heat, tenderness,
5–6 cm (2.0 to 2.4 in.) below normal nipple cracked or fissured nipple (infection)
line

Axillary nodes nonpalpable or pellet sized Tenderness, enlargement, hard node Refer to healthcare provider for evaluation of abnormal
(carcinoma); may be visible bump ​‐ breast findings. Plan ultrasound/mammogram/MRI of
(infection) breasts.

Pregnancy changes:

1. Size increase noted primarily in Discuss normalcy of changes and their meaning with the
first 20 weeks. woman. Teach and/or institute appropriate relief
2. Become nodular. measures. Encourage use of supportive, well-fitting
3. Tingling sensation may be felt during brassiere.
first and third trimester; woman may
report feeling of heaviness.
4. Pigmentation of nipples and areolae
darkens.
5. Superficial veins dilate and become
more prominent.
6. Striae seen in multiparas.
7. Tubercles of Montgomery enlarge.
8. Colostrum may be present after
12th week.
9. Secondary areola appears at
20 weeks, characterized by series of
washed-out spots surrounding
primary areola.
10. Breasts less firm, old striae may be
present in multiparas.

Heart

Normal rate, rhythm, and heart sounds Enlargement, thrills, thrusts, gross Complete an initial assessment. Explain normal
irregularity or skipped beats, gallop pregnancy-induced changes. Refer to healthcare
rhythm or extra sounds (cardiac provider if indicated.
disease)

Pregnancy changes:

1. Palpitations may occur due to

sympathetic nervous system
disturbance.
2. Short systolic murmurs that increase
in held expiration are normal due to
increased volume.

Abdomen

Normal appearance, skin texture, and hair Size of uterus inconsistent with length of Assure woman of normalcy of diastasis. Provide initial
distribution; liver nonpalpable; abdomen gestation (intrauterine growth restriction information about appropriate prenatal and postpartum
nontender [IUGR], multiple pregnancy, fetal exercises. Evaluate woman’s anxiety level. Refer to
demise, incorrect estimated date of healthcare provider if indicated.
Pregnancy changes:
birth (EDB), abnormal amniotic fluid,
Reassess menstrual history regarding pregnancy dating.
1. Purple striae may be present (or hydatidiform mole)
Evaluate increase in size using McDonald method. (See
silver striae on a multipara) as well as
Failure to hear fetal heartbeat with Figure 9-3.) Use ultrasound to establish diagnosis.
linea nigra.
Doppler (fetal demise, hydatidiform
2. Diastasis of the rectus muscles is Refer to healthcare provider. Administer pregnancy
mole)
seen late in pregnancy. tests.
3. Size: Flat or rotund abdomen; Failure to feel fetal movements after 20
Use ultrasound to establish diagnosis.
progressive enlargement of uterus weeks’ gestation (fetal demise,
due to pregnancy: hydatidiform mole) Refer to healthcare provider.
10–12 weeks: Fundus slightly
No ballottement (oligohydramnios) Refer to healthcare provider.
above symphysis pubis.

16 weeks: Fundus halfway

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between symphysis and umbilicus.
 20–22 weeks: Fundus at
umbilicus.

28 weeks: Fundus three finger

breadths above umbilicus.

36 weeks: Fundus just below

ensiform cartilage.

4. Fetal heart rate: 110–160 beats/min

may be heard with Doppler at 10–12
weeks’ gestation; may be heard with
fetoscope at 17–20 weeks.
5. Fetal movement palpable by a trained
examiner after the 18th week.
6. Ballottement: During fourth to
fifth month, fetus rises and then
rebounds to original position when
uterus is tapped sharply.

Extremities

Skin warm, pulses palpable, full range of Unpalpable or diminished pulses Evaluate for other symptoms of heart disease; initiate
motion; may be some edema of hands and (arterial insufficiency); marked edema follow-up if woman mentions that her rings feel tight.
ankles in late pregnancy; varicose veins (preeclampsia) Discuss prevention and self-treatment measures for
may become more pronounced; palmar varicose veins; refer to healthcare provider if indicated.
erythema may be present

Spine

Normal spinal curves: Concave cervical, Abnormal spinal curves; flatness, Refer to healthcare provider if indicated.
convex thoracic, concave lumbar kyphosis, lordosis
May have implications for administration of spinal
In pregnancy, lumbar spinal curve may be Backache anesthetics
accentuated

Shoulders and iliac crests should be even Uneven shoulders and iliac crests Refer very young women to healthcare provider; discuss
(scoliosis) back-stretching exercise with older women.

Reflexes

Normal and symmetric Hyperactivity, clonus (preeclampsia) Evaluate for other symptoms of ​preeclampsia.

Pelvic Area

External female genitals: Normally formed Lesions, genital warts, hematomas, Explain pelvic examination procedure. Encourage woman
with female hair distribution; in multiparas, varicosities, inflammation of Bartholin to minimize her discomfort by relaxing her hips. Provide
labia majora loose and pigmented; urinary glands; clitoral hypertrophy privacy.
and vaginal orifices visible and (masculinization)
appropriately located

Vagina: Pink or dark pink, vaginal Abnormal discharge associated with Obtain vaginal smear. Provide understandable verbal
discharge odorless, nonirritating; in vaginal infections and written instructions about treatment for woman and
multiparas, vaginal folds smooth and partner, if indicated.
flattened; may have episiotomy scar

Cervix: Pink color; os closed except in Eversion, reddish erosion, nabothian or Provide woman with a hand mirror and identify genital
multiparas, in whom os admits fingertip retention cysts, cervical polyp; granular structures for her; encourage her to view her cervix if
area that bleeds (carcinoma of cervix); she wishes. Refer to healthcare provider if indicated.
lesions (herpes, human papillomavirus Advise woman of potential serious risks of leaving an IUD
[HPV]); presence of string or plastic tip in place during pregnancy; refer to healthcare provider
from cervix (intrauterine device [IUD] in for removal.
uterus)

Pregnancy changes:

1–4 weeks’ gestation: enlargement in Absence of Goodell sign (inflammatory Refer to healthcare provider.
anteroposterior diameter conditions, carcinoma)

4–6 weeks’ gestation: softening of cervix

(Goodell sign); softening of isthmus of
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 uterus ​(Hegar sign); cervix takes on bluish
coloring (Chadwick sign)

8–12 weeks’ gestation: vagina and cervix

appear bluish violet in color (Chadwick sign)

Uterus: Pear shaped, mobile; smooth Fixed (pelvic inflammatory disease Refer to healthcare provider.
surface [PID]); nodular surface (fibromas)

Ovaries: Small, walnut shaped, nontender Pain on movement of cervix (PID); Evaluate adnexal areas; refer to healthcare provider.
(ovaries and fallopian tubes are located in enlarged or nodular ovaries (cyst,
the adnexal areas) tumor, tubal pregnancy, corpus luteum
of pregnancy)

Pelvic Measurements

Internal measurements:

1. Diagonal conjugate at least 11.5 cm Measurement below normal Vaginal birth may not be possible if deviations are
(4.5 in.) (see Figure 9–5 ) present.
Disproportion of pubic arch
2. Obstetric conjugate estimated by
subtracting 1.5–2.0 cm (0.60 to 0.79 Abnormal curvature of sacrum
in.) from diagonal conjugate
Fixed or malposition of coccyx
3. Inclination of sacrum
4. Motility of coccyx; external
intertuberosity diameter greater than
8 cm (3.15 in.)

Anus and Rectum

No lumps, rashes, excoriation, tenderness; Hemorrhoids, rectal prolapse; warts Counsel about appropriate prevention and relief
cervix may be felt through rectal wall (HPV infection); nodular lesion ​‐ measures; refer to healthcare provider for further
(carcinoma) evaluation.

Laboratory

Evaluation

Hemoglobin: 12–16 g/dL; women residing Less than 11.0 g/dL in the first trimester, Hemoglobin less than 12 g/dL requires nutritional
in areas of high altitude may have higher less than 10.5 g/dL in the second counseling; less than 11 g/dL requires iron
levels of hemoglobin trimester, and less than 11.0 g/dL in the supplementation.
third trimester (anemia) (King et al.,
2015)

ABO and Rh typing: Normal distribution Rh negative If Rh negative, check for presence of anti-Rh antibodies.
of blood types Check blood type of father of child; if he is Rh positive,
discuss with woman the need for Rh immune globulin
administration at 28 weeks, management during the
intrapartum period, and possible need for Rh immune
globulin after birth. (See discussion in Chapter 15 .)

Complete Blood Count (CBC)

Hematocrit: 38%–47% physiologic anemia Marked anemia or blood dyscrasias Perform CBC and Schilling differential cell count.
(pseudoanemia) may occur

Red blood cells (RBC): 4.2–5.4

million/mcL

White blood cells (WBC): 5000– Presence of infection; may be elevated Evaluate for other signs of infection.
12,000/mcL in pregnancy and with labor

Differential

Neutrophils: 40%–60%

Bands: up to 5%

Eosinophils: 1%–3%

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 Basophils: up to 1%

Lymphocytes: 20%–40%

Monocytes: 4%–8%

First-trimester aneuploidy screening Increased nuchal translucency, ​elevated If findings are positive, genetic counseling and diagnostic
(testing to detect conditions related to β-hCG, and reduced pregnancy-​‐ testing using chorionic villus sampling (CVS) or second-
abnormal chromosome number): If nuchal associated plasma protein A (PAPP-A) trimester amniocentesis are offered.
translucency (NT) testing is available, offer (Down syndrome, trisomy 18, trisomy
first-trimester screening for Down 13)
syndrome using nuchal translucency and
serum markers (PAPP-A and free β-hCG).
Normal range.

Integrated screening: Combines first-

trimester aneuploidy screening results with
second-trimester quadruple (quad) screen
to detect aneuploidy and neural tube
defects; may be used in areas in which NT
testing is not available. (See discussion in
Assessment Guide: Subsequent Prenatal
Assessment.)

Syphilis tests: Serologic tests for syphilis Positive reaction STS—tests may have Positive results may be confirmed with the fluorescent
(STS), complement fixation test, Venereal 25%–45% incidence of biologic false- treponemal antibody-absorption (FTA-ABS) test; all tests
Disease Research Laboratory (VDRL) test– positive results; false results may occur for syphilis give positive results in the secondary stage of
nonreactive in individuals who have acute viral or the disease; antibiotic tests may cause negative test
bacterial infections, hypersensitivity results. Refer to healthcare provider for treatment.
reactions, recent vaccinations, collagen
disease, malaria, or tuberculosis
bacterial infections

Gonorrhea culture: Negative Positive Refer for treatment.

Urinalysis (u/a): Normal color, specific Cloudy appearance (infection; pus or Repeat u/a; refer to healthcare ​provider.
gravity; pH 4.6–8 tissue)

Abnormal color (porphyria, hemoglo-

binuria, bilirubinemia): alkaline urine
(metabolic alkalemia, Proteus infection,
old specimen)

Negative for protein, red blood cells, white Positive findings (contaminated Repeat u/a; urine culture with sensitivities if bacteria
blood cells, casts specimen, urinary tract infection (UTI), detected; refer to healthcare provider.
kidney disease)

Negative for glucose (small degree of Glycosuria (low renal threshold for Assess blood glucose level; test urine for ketones.
glycosuria may occur in pregnancy) glucose, diabetes mellitus)

Urine culture: Negative for bacteria Bacteria (UTI) If bacteria detected, refer to healthcare provider for
treatment.

Rubella titer: Hemagglutination-inhibition HAI titer less than 1:10 Immunization will be given postpartum. Instruct woman
(HAI) test–1:10 or above indicates woman is whose titers are less than 1:10 to avoid children who
immune have rubella.

Hepatitis B screen: For hepatitis B Positive If positive, refer to physician. Babies born to women who
surface antigen (HBsAg): negative test positive are given hepatitis B immune globulin soon
after birth followed by first dose of hepatitis B vaccine.
Note: Women with risk factors are also
tested for hepatitis C (spread by direct
contact with infected blood

HIV screen: Completed on all pregnant Positive Refer to healthcare provider.

woman unless woman specifically opts out
of screening; negative

Illicit drug screen: Offered to all women; Positive Refer to healthcare provider.
negative

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 Sickle cell screen for clients of African Positive; test results would include a Refer to healthcare provider.
or Latino descent: Negative description of cells

Pap smear: If indicated because the Test results that show abnormal cells Refer to healthcare provider. Discuss with the woman the
woman is due for the test; negative with negative or positive high-risk HPV. meaning of the findings and the importance of follow-up.
Plan colposcopy if indicated.

Determine the woman’s fluency in written Woman may be fluent in language other Work with a knowledgeable translator to provide
and oral English. than English. information and answer questions.

Ask the woman how she prefers to be Some women prefer informality; others Address the woman according to her preference.
addressed. Nickname? prefer to use titles. Maintain formality in introducing oneself if that seems
preferred.

Determine customs and practices regarding Practices are influenced by individual Honor a woman’s practices and provide for specific
prenatal care: preference, cultural expectations, or preferences unless they are contraindicated because of
religious beliefs. safety.
Ask the woman if there are certain
practices she expects to follow when she is Some women are comfortable only with
pregnant. a female caregiver.

Ask the woman if there are any activities

she cannot do while she is pregnant.
Ask the woman whether there are
certain foods she is expected to eat or
avoid while she is pregnant. Determine
whether she has lactose intolerance.
Ask the woman whether the gender of
her caregiver is of concern.
Ask the woman about the degree of
involvement in her pregnancy that she
expects or wants from her support
person, mother, and other significant
people.
Ask the woman about her sources of
support and counseling during
pregnancy.

Psychologic Status

Excitement and/or apprehension, ​‐ Marked anxiety (fear of pregnancy Establish lines of communication. Active listening is
ambivalence diagnosis, fear of medical facility) useful. Establish trusting relationship. Encourage woman
to take active part in her care.

Apathy; display of anger with pregnancy Establish communication and begin counseling. Use
diagnosis active listening ​techniques.

Educational Needs

May have questions about pregnancy or Establish educational, supporting environment that can
may need time to adjust to reality of be expanded throughout pregnancy.
pregnancy

Support System

Can identify at least two or three individuals Isolated (no telephone, unlisted Institute support system through community groups.
with whom woman is emotionally intimate number); cannot name a neighbor or Help woman to develop trusting relationship with
(partner, parent, sibling, friend) friend whom she can call on in an healthcare professionals.
emergency; does not perceive parents
as part of her support system

Family Functioning

Emotionally supportive Long-term problems or specific Help identify the problems and stressors, encourage
problems related to this pregnancy, communication, and discuss role changes and
Communications adequate
potential stressors within the family, adaptations. Refer to counseling if indicated.
Mutually satisfying pessimistic attitudes, unilateral decision
making, unrealistic expectations of this
Cohesiveness in times of trouble
pregnancy or child

Economic Status

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 Source of income is stable and sufficient to Limited prenatal care; poor physical Discuss available resources for health maintenance and
meet basic needs of daily living and health; limited use of healthcare system; the birth. Institute appropriate referral for meeting
medical needs unstable economic status expanding family’s needs—food stamps, WIC (a federally
funded nutrition program for women, infants, and
children), and so forth.

Stability of Living Conditions

Adequate, stable housing for expanding Crowded living conditions; questionable Refer to appropriate community agency. Work with
family’s needs supportive environment for newborn family on self-help ways to improve situation.

* Possible causes of alterations are identified in parentheses.

† This column provides guidelines for further assessment and initial intervention.

Determination of Due Date

Childbearing families generally want to know the “due date,” or the date around which childbirth will occur. Historically,
the due date has been called the estimated date of confinement (EDC). However, the concept of confinement is rather
negative, and many caregivers avoid it by referring to the due date as the estimated date of delivery (EDD). Childbirth
educators often stress that babies are not “delivered” like a package; they are born. In keeping with a view that
emphasizes the normality of the process, the authors of this text refer to the due date as the estimated date of birth
(EDB) .

To calculate the EDB, it is essential to know the first day of the last menstrual period (LMP). However, some women
have episodes of irregular bleeding or fail to keep track of menstrual cycles. Thus other techniques also help to
determine how far along a woman is in her pregnancy—that is, at how many weeks’ gestation she is. Techniques
include evaluating uterine size, determining when quickening occurs (or occurred), using early ultrasound, and
auscultating fetal heart rate with a Doppler device or ultrasound. An early ultrasound should be obtained if an accurate
LMP is not available to help establish an accurate EDB.

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 Nägele’s Rule
The most common method of determining the EDB is Nägele’s rule , which uses 280 days as the mean
length of pregnancy. To use this method, begin with the first day of the LMP, subtract 3 months, and add 7 days. For
example:

First day of LMP November 21

Subtract 3 months − 3 months

August 21

Add 7 days + 7 days

EDB (of the next year) August 28

It is simpler to change the months to numeric terms:

November 21 becomes 11–21

Subtract 3 months −3 months

8–21

Add 7 days + 7 days

EDB (of the next year) 8–28

A gestation calculator or wheel lets the caregiver calculate the EDB even more quickly (Figure 9–1 ).

Developing Cultural Competence Using Cultural Information

Effectively
Although it is important to avoid stereotyping, race and ethnicity may provide valuable starting information about
cultural, behavioral, environmental, and medical factors that might affect a pregnant woman’s health. With this
general knowledge as a framework, it is essential to ask the woman about specific practices in her culture to
determine their meaning for her.
Nägele’s rule may be a fairly accurate determiner of the EDB if the woman has a history of menses every 28 days,
remembers her LMP, and was not taking oral contraceptives before becoming pregnant. However, ovulation usually
occurs 14 days before the onset of the next menses, not 14 days after the previous menses. Consequently, if a
woman’s cycle is irregular, or more than 28 days long, the time of ovulation may be delayed. If a woman has been
using oral contraceptives, ovulation may be delayed several weeks following her last menses. Then, too, a postpartum
woman who is breastfeeding may resume ovulating but be amenorrheic for a time, making calculation based on the
LMP impossible. Thus Nägele’s rule, although helpful, is not foolproof and, in such cases, an ultrasound is done to
visualize the gestational sac and obtain measurements of the embryo-fetus to determine EDB.

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 Uterine Assessment

Physical Examination
When a woman is examined in the first 10 to 12 weeks of her pregnancy and her uterine size is compatible with her
menstrual history, uterine size may be the single most important clinical method for dating her pregnancy. In many
cases, however, women do not seek maternity care until well into their second trimester, when it becomes much more
difficult to evaluate specific uterine size. In women who are obese, it is difficult to determine uterine size early in a
pregnancy because the uterus is more difficult to palpate.

Fundal Height
Fundal height may be used as an indicator of uterine size, although this method is less accurate late in pregnancy. A
tape measure is used to measure the distance in centimeters from the top of the symphysis pubis to the top of the
uterine fundus (McDonald method) (Figure 9–2 ). Fundal height in ​centimeters correlates well with weeks of
gestation between 22 and 34 weeks. Thus, at 26 weeks’ gestation, for example, fundal height is probably about 26 cm
(10.25 in.). If the woman is very tall or very short, fundal height will differ. To be most accurate, fundal height should be
measured by the same examiner each time. The woman should have voided within one half hour of the examination
and should lie in the same position each time. In the third trimester, variations in fetal weight decrease the accuracy of
fundal height measurements.

A lag in progression of measurements of fundal height from month to month and week to week may signal intrauterine

Figure 9–1
The EDB wheel can be used to calculate the due date. To use it, place the “last menses began” arrow on the date of the
woman’s LMP. Then read the EDB at the arrow labeled 40. In this case, the LMP is September 8, and the EDB is June 15.

growth restriction (IUGR). A sudden increase in fundal height may indicate twins or hydramnios (excessive amount of
amniotic fluid).

Assessment of Fetal Development

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 Quickening
Fetal movements felt by the mother, called quickening, may indicate that the fetus is nearing 20 weeks’ gestation.
However,

Figure 9–2
A cross-sectional view of fetal position when the McDonald method is used to assess fundal height.

Figure 9–3
This practitioner is using an ultrasonic Doppler device to listen to the fetal heartbeat.

quickening may be experienced between 16 and 22 weeks’ ​gestation, so this method is not completely accurate.

Fetal Heartbeat
The ultrasonic Doppler device (Figure 9–3 ) is the primary tool for assessing fetal heartbeat. It can detect fetal
heartbeat, on average, at 8 to 12 weeks’ gestation. The normal range for fetal heart tones (FHTs) is 110 to 160
beats/min. An ultrasound should be completed if the nurse is unable to auscultate between 10 and 12 weeks because
there may be a discrepancy in the EDB, twins, or a missed abortion. In the case of twins or a woman with obesity, it
may be later before the fetal heartbeat can be detected.

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 Ultrasound
Transvaginal ultrasound is often used in early pregnancy; after about 10 weeks, transabdominal ultrasound is indicated
(ACOG, 2013d). In the first trimester (up to and including 13 6/7 weeks’ gestation), ultrasound can detect a gestational
sac as early as 5 weeks after the LMP, fetal heart activity by 6 to 7 weeks, and fetal breathing movements by 10 to 11
weeks of pregnancy. Crown-to-rump measurements can be made to assess fetal age from 5 to 6 weeks until about 12
weeks (until the fetal head can be visualized clearly). Biparietal diameter (BPD) can then be used. BPD measurements
can be made by approximately 12 to 13 weeks and are most accurate between 14 and 26 weeks, when rapid growth in
the biparietal diameter occurs. (See Chapter 13 for further discussion of fetal ultrasound scanning.)

Assessment of Pelvic Adequacy (Clinical Pelvimetry)

The pelvis can be assessed vaginally to determine whether its size is adequate for a vaginal birth. This procedure,
clinical pelvimetry, is performed by physicians or by advanced practice nurses such as CNMs or nurse practitioners. For
a detailed description of how clinical pelvimetry is done, refer to a nurse-midwifery text. This section provides basic
information about

Evidence-Based Practice Determination of Gestational Age Using

Ultrasound
Clinical Question
Is ultrasound biometry an accurate way of determining the gestational age of a fetus?

The Evidence
Accurate gestational dating is an important part of prenatal care. Assessment of fetal growth and development,
timely screening tests, and maternal preparation for birth depend on having an accurate prediction of fetal
maturity. In addition, accurate assignment of gestational age may reduce the rate of labor induction for post-date
pregnancy. Three Canadian obstetricians and a consulting committee of diagnostic radiologists used strict review
criteria to evaluate a dozen research studies relative to the safety and effectiveness of ultrasound for gestational
dating. The resulting guideline forms the strongest level of evidence for clinical practice.

The strongest evidence supports first trimester crown-rump length as the best parameter for determining
gestational age (Butt & Lim, 2014). Between the 12th and 14th weeks, crown-rump length and biparietal
diameter are similar in accuracy. Abdominal ultrasound is as accurate as transvaginal ultrasonography, although
the latter is more accurate for visualizing early embryonic structures. If ultrasound is used in the second or third
trimester, gestational age is best determined by a combination of multiple biometric parameters, including
biparietal diameter, head circumference, abdominal circumference, and femur length. During the second and
third trimesters, no single measure best predicts gestational age. The most difficult time to determine a due date
is during the third trimester. When performed accurately and precisely, ultrasound is more accurate than even a
“certain” missed menstrual date for determining gestational age in spontaneous conceptions. It is the best
method for estimating the birth date.

Best Practice
Ideally, every pregnant woman should be offered a first-trimester ultrasound to determine gestational age.
Abdominal ultrasound is as accurate as transvaginal ultrasound and is more comfortable for the mother. Dating
can still be accomplished later in the pregnancy, but ultrasound becomes a less accurate predictor as gestation
progresses through the second and third trimesters.

Clinical Reasoning
What are some of the reasons that an accurate gestational age is important to prenatal care? Can a case be
made for the cost-effectiveness of early ultrasound to determine an accurate birth due date?

the assessment of the inlet and outlet, which were described in detail in Chapter 4 .

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 1. Pelvic inlet (Figure 9–4 ):
Diagonal conjugate (the distance from the lower posterior border of the symphysis pubis to the sacral
promontory): at least 11.5 cm (4.5 in.)
Obstetric conjugate (a measurement approximately 1.5 cm (0.60 in.) smaller than the diagonal conjugate):
10.0 cm (3.9 in.) or more

2. Pelvic outlet (Figures 9–4 and 9–5 ):

Anteroposterior diameter: 9.5 to 11.5 cm (3.75 to 4.5 in.)
Transverse diameter (bi-ischial or intertuberous diameter): 8 to 10 cm (3.15 to 3.9 in.)

The pelvic cavity (midpelvis) cannot be accurately measured by clinical examination. Examiners estimate its adequacy.

Figure 9–4
Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border
of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which
extends from the lower border of the symphysis pubis to the tip of the sacrum.

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 Figure 9–5
Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal
knuckles. If they do not, they can use a measuring device.

Screening Tests
Many screening tests are routinely performed and/or offered either at the initial prenatal visit or at a specified time
during pregnancy. These tests include a Pap smear if indicated, a complete blood count, HIV screening, urine culture,
rubella titer, ABO and Rh typing, and a hepatitis B screen as well as testing for sexually transmitted infections such as
syphilis, chlamydial infection, and gonorrhea. The urine is screened for abnormal findings initially and at each prenatal
visit.

Hemoglobin electrophoresis should be performed in women of African, Southeast Asian, and Mediterranean descent to
evaluate for sickle cell disease and thalassemias. Prenatal screening for cystic fibrosis has been a routine screening test
for all pregnant women for over a decade. To avoid redundant testing, caregivers should determine whether the woman
was screened for cystic fibrosis during a previous pregnancy (ACOG, 2011).

A tuberculin test (either purified protein derivative [PPD] or Quantiferon Gold) should also be completed on women who
are considered to be high risk. High-risk populations include women who were not born in the United States or who
have a known exposure to tuberculosis and healthcare workers who care for clients with tuberculosis.

All pregnant women, regardless of age, should be offered screening for fetal chromosomal anomalies (aneuploidy),
including Down syndrome, trisomy 18, trisomy 13, and Turner syndrome. First-trimester screening is available at many
centers using ultrasound assessment of the thickness of the fetal nuchal fold (called nuchal translucency [NT])
combined with serum screening for free β-hCG and for pregnancy-associated plasma protein A (PAPP-A). Increased NT,
elevated free β-hCG, and reduced PAPP-A suggest aneuploidy. Women with these findings are offered genetic
counseling and chorionic villus sampling or second-trimester amniocentesis for diagnosis. If these tests are all negative,
no further testing is indicated. Instead, during the second trimester, the woman is simply offered a test for maternal
serum alpha-fetoprotein to detect the risk of neural tube defects.

The quadruple screen (quad screen) is a safe, useful screening test performed on the mother’s serum between weeks
15 and 20 of pregnancy. The test is used to detect levels of specific serum markers—alpha-fetoprotein (AFP), human
chorionic gonadotropin (hCG), unconjugated estriol (UE), and inhibin-A (a placental hormone). Test results that reveal
higher than normal AFP levels might indicate an increased risk of a fetal neural tube defect, a multiple gestation, or a
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 pregnancy that is further along than believed. Lower than normal AFP could indicate that the woman’s child is at risk for
Down syndrome or trisomy 18. Higher than normal levels of hCG and inhibin-A and lower than normal UE may also
indicate that a woman is at increased risk of having a baby with Down syndrome.

NT evaluation requires a skilled ultrasonographer and specialized training. In areas where NT is not available, first-
trimester free β-hCG screening and PAPP-A screening may be combined with second-trimester quad screening in an
integrated approach to detection of aneuploidy.

Noninvasive prenatal testing for fetal aneulopoidy (trisomy), specifically trisomy 13, trisomy 18, and trisomy 21 is also
available using cell free fetal DNA (cffDNA) from the blood of pregnant women. Cell free fetal DNA is thought to be
derived from the placenta and can be collected as early as 10 weeks’ gestation. Currently ACOG (2012) does not
recommend this testing as routine screening for all women, but it can serve as a primary screening test for women at
high risk of a trisomy.

It is important for healthcare professionals to provide parents with factual information about the results of tests that
detect chromosomal defects or fetal anomalies including the false-positive and detection rates and the implications of
the findings. Parents then need to decide on any course of action based on their own spiritual and cultural beliefs.

Screening for gestational diabetes mellitus (GDM) is typically completed between 24 and 28 weeks’ gestation. ACOG
(2013b) recommends that the testing be done using a 50 g 1-hour glucose screen. If results are abnormal, diagnostic
testing using a 100-g, 3-hour oral glucose tolerance test is indicated (for a discussion of GDM, see Chapter 14 ). The
American Diabetes Association (2011) recommends that pregnant women at average risk should have a diagnostic
test 24 to 28 weeks’ gestation using a 75-g 2-hour oral glucose tolerance test (OGTT). A Consensus Conference
convened to evaluate the two approaches recommends the two-step approach with screening followed by diagnostic
testing if screening results are abnormal, as advocated by ACOG (VanDorsten et al., 2013). A hemoglobin or
hematocrit is also completed at this time to evaluate for iron deficiency anemia.

Group B streptococcus (GBS) can cause serious problems for a newborn. Consequently, rectal and vaginal swabs of the
mother are taken at 35 to 37 weeks’ gestation to screen for the infection. Women with GBS in the urine at any time
during the pregnancy are considered to be positive and do not need a culture completed. This infection is discussed in
more detail in Chapter 14 .

Additional tests are completed in the event of pathologic findings or known disease states. For example, a woman with
known chronic hypertension should have a 24-hour urine, metabolic panel, and uric acid completed.

Subsequent Client History

At subsequent prenatal visits the nurse continues to gather data about the course of the pregnancy to date and the
woman’s responses to it. The nurse also asks about:

Adjustment of the support person and of other children, if any, in the family
Preparations the family has made for the new baby
Discomfort, especially the kinds of discomfort that are often seen at specific times during a pregnancy
Physical changes that relate directly to the pregnancy, such as fetal movement
Exposure to contagious illnesses
Medical treatments and therapies prescribed for nonpregnancy problems since the last visit
Consumption of prescription or over-the-counter medications or herbal supplements that were not prescribed as part
of the woman’s prenatal care
Use of complementary and alternative therapies
Danger signs of pregnancy (Table 9–2 ). (Note: Many of the danger signs indicate conditions that are potential
complications.)

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 Table 9–2 Danger Signs in Pregnancy

The woman should report the following ​danger signs in ​pregnancy immediately:

Danger Sign Possible Cause

Sudden gush of fluid from vagina Premature rupture of membranes

Vaginal bleeding Abruptio placentae, placenta previa

Lesions of cervix or vagina

“Bloody show”

Abdominal pain Premature labor, abruptio placentae

Temperature above 101.0°F (38.3°C) and chills Infection

Dizziness, blurring of vision, double vision, spots before eyes Hypertension, preeclampsia

Persistent vomiting Hyperemesis gravidarum

Severe headache Hypertension, preeclampsia

Edema of hands, face, legs, and feet Preeclampsia

Muscular irritability, convulsions Preeclampsia, eclampsia

Epigastric pain Preeclampsia, ischemia in major abdominal vessel

Oliguria Renal impairment, decreased fluid intake

Dysuria Urinary tract infection

Absence of fetal movement Maternal medication, obesity, fetal death

Periodic prenatal examinations offer a chance to assess the childbearing woman’s psychologic needs and emotional
status. If the woman’s partner attends the antepartum visits, they can also be a time to identify the partner’s needs and
concerns. The woman should have sufficient time to ask questions and air concerns. If a nurse provides the time and
demonstrates genuine interest, the woman will be more at ease bringing up questions that she may believe are silly or
has been afraid to verbalize.

Be sensitive to religious or spiritual, cultural, and socioeconomic factors that may influence a family’s response to
pregnancy, as well as to the woman’s expectations of the healthcare system. One way to avoid stereotyping clients is
simply to ask each woman about her expectations for the antepartum period. Although many women’s responses may
reflect what are thought to be traditional norms, other women will have decidedly different views or expectations that
represent a blending of beliefs or cultures. During the antepartum period, it is also essential to begin assessing the
readiness of the woman and her partner (if possible) to assume their responsibilities as parents successfully.

Subsequent Prenatal Assessment

Assessment Guide: Subsequent Prenatal Assessment provides a systematic approach to the regular physical
examinations the pregnant woman should undergo for optimal antepartum care and also provides a model for
evaluating both the pregnant woman and the expectant father, if he is involved in the pregnancy.

The recommended frequency of antepartum visits in an uncomplicated pregnancy is as follows:

Every 4 weeks for the first 28 weeks’ gestation

Every 2 weeks until 36 weeks’ gestation
After week 36, every week until childbirth

During the subsequent antepartum assessments, most women demonstrate ongoing psychologic adjustment to
pregnancy. However, some women may exhibit signs of possible psychologic problems such as the following:

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 Increasing anxiety
Inability to establish communication
Inappropriate responses or actions
Denial of pregnancy
Inability to cope with stress
Intense preoccupation with the gender of the baby
Failure to acknowledge quickening
Failure to plan and prepare for the baby (e.g., living arrangements, clothing, and feeding methods)
Indications of substance abuse

If the woman’s behavior indicates possible psychologic problems, the nurse can provide ongoing support and
counseling and also refer the woman to appropriate professionals.

Clinical Tip

When assessing blood pressure, have the pregnant woman sit up with her arm resting on a table so that her arm
is at the level of her heart. Expect a decrease in her blood pressure from baseline during the second trimester
because of normal physiologic changes.

Assessment Guide Subsequent Prenatal Assessment

Physical Assessment/Normal Findings Alterations and Possible Causes* Nursing Responses to Data†

Vital Signs

Temperature: 97.0°–99.6°F (36.2°–37.6°C) Elevated temperature (infection) Evaluate for signs of infection. Refer to
healthcare provider.

Pulse: 60–100 beats/min Increased pulse rate (anxiety, cardiac Note irregularities. Assess for anxiety and
disorders) stress.

Rate may increase 10 beats/min during pregnancy.

Respiration: 12–20 breaths/min Marked tachypnea or abnormal patterns Refer to healthcare provider.
(respiratory disease)

Blood pressure: Less than or equal to 120/80 (falls BP of 120–139/80–89 is considered Assess for edema, proteinuria, and
in second trimester) prehypertensive. Greater than 140/90 or hyperreflexia. Refer to healthcare provider.
increase of 30 mmHg systolic and
15 mmHg diastolic (preeclampsia)

Schedule appointments more frequently.

Weight Gain

Prepregnant weight based on body mass index

(BMI):

Normal BMI: Total recommended weight gain 11.5–

16 kg (25–35 lb)

First trimester: 1.6–2.3 kg (3.5–5.0 lb) Inadequate weight gain (poor nutrition, Discuss appropriate weight gain.
nausea, IUGR)

Second trimester: 5.5–6.8 kg (12–15 lb) Third Excessive weight gain (excessive caloric Provide nutritional counseling. Assess for
trimester: 5.5–6.8 kg (12–15 lb) intake, edema, preeclampsia) presence of edema or anemia. Refer to a
dietitian as needed.

Edema

Small amount of dependent edema, especially in last Marked edema in hands, face, legs, and Identify any correlation between edema and
weeks of pregnancy feet (preeclampsia) activities, blood pressure, or proteinuria:
Refer to healthcare provider if indicated.

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 Uterine Size

See Assessment Guide: Initial Prenatal Assessment Unusually rapid growth (multiple Evaluate fetal status. Determine height of
for normal changes during pregnancy gestation, hydatidiform mole, hydramnios, fundus. Use diagnostic ultrasound.
miscalculation of EDB)

Fetal Heartbeat

110–160 beats/min Funic souffle Absence of fetal heartbeat after 20 weeks’ Evaluate fetal status.
gestation (maternal obesity, fetal demise)

Laboratory Evaluation

Hemoglobin: 12–16 g/dL Pseudoanemia of Less than 11 g/dL (anemia) Provide nutritional counseling. Hemoglobin is
pregnancy repeated at 7 months’ gestation. Women of
Mediterranean heritage need a close check
on hemoglobin because of possibility of
thalassemia.

Quad marker screen: Blood test performed at 15– Elevated MSAFP (neural tube defect, Offered to all pregnant women. If quad
21 weeks’ gestation but best performed between 16 underestimated gestational age, multiple screen is abnormal, further testing such as
and 18 weeks’ gestation. Evaluates four ​factors: gestation); lower than normal MSAFP ultrasound or amniocentesis may be
maternal serum alpha-fetoprotein (MSAFP), (Down syndrome, trisomy 18); higher than indicated.
unconjugated estriol (UE), hCG, and inhibin-A: normal normal hCG and inhibin-A (Down
levels syndrome); lower than normal UE (Down
syndrome)

Indirect Coombs test done on Rh-negative women: Rh antibodies present (maternal If Rh negative and unsensitized, Rh immune
Negative (done at 28 weeks’ gestation) sensitization has occurred) globulin given (see discussion in
Chapter 15 ). If Rh antibodies present,
Rh immune globulin not given; fetus
monitored closely for isoimmune hemolytic
disease.

50-g 1-hour glucose screen (done between 24 and Plasma glucose level greater than Refer for a diagnostic 100-g oral glucose
28 weeks’ gestation) 140 mg/dL (gestational diabetes ​mellitus tolerance test. Discuss implications of
[GDM]) gestational diabetes mellitus (GDM) if
diagnosis is made. Refer to healthcare
provider.

Urinalysis: See Assessment Guide: Initial Prenatal See Assessment Guide: Initial Prenatal Urinalysis and culture is completed at initial
Assessment for normal findings Assessment for deviations visit and at subsequent visits as indicated.

Repeat dipstick test at each visit.

Protein: Negative Proteinuria, albuminuria (contamination Obtain dipstick urine sample. Refer to
by vaginal discharge, urinary tract healthcare provider if deviations are present.
infection, preeclampsia)

Glucose: Negative Persistent glycosuria (diabetes mellitus) Refer to healthcare provider.

Note: Glycosuria may be present due to physiologic

alterations in glomerular filtration rate and renal
threshold

Screening for Group B streptococcus (GBS): Positive culture (maternal infection) Explain maternal and fetal/neonatal risks
(see Chapter 15 ).

Rectal and vaginal swabs obtained at 35–37 weeks’ Refer to healthcare provider for therapy.
gestation for all pregnant women.

Determine the mother’s (and family’s) attitudes about Some women have no preference about Provide opportunities to discuss preferences
the gender of the unborn child. the gender of the child; others do. In and expectations; avoid a judgmental
many cultures, boys are especially ​valued attitude to the response.
as firstborn children.

Ask about the woman’s expectations of childbirth. Will Some women want their partner present Provide information on birth options but
she want someone with her for the birth? Whom does for labor and birth; others prefer a female accept the woman’s decision about who will
she choose? What is the role of her partner? relative or friend. attend.

Some women expect to be separated from

their partner once labor begins.
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 Ask about preparations for the baby. Determine what Some women may have a fully prepared Explore reasons for not preparing for the
is customary for the woman. nursery; others may not have a separate baby. Support the mother’s preferences and
room for the baby. provide information about possible sources
of assistance if the decision is related to a
lack of resources.

Expectant Mother

Psychologic status Increased stress and anxiety Encourage woman to take an active part in
her care.

First trimester: Period of adjustment. Incorporates Inability to establish communication; Establish lines of communication. Discuss
idea of pregnancy; may feel ambivalent or anxious, inability to accept pregnancy; and provide anticipatory guidance regarding
especially if she must give up desired role; usually inappropriate response or actions; denial normalcy of feelings and actions. Establish a
looks for signs of verification of pregnancy, such as of pregnancy; inability to cope trusting relationship. Counsel as necessary.
increase in abdominal size or fetal movement. Refer to appropriate professional as needed.

Second trimester: Period of radiant health. Baby

becomes more real to woman as abdominal size
increases and she feels movement; she begins to turn
inward, becoming more introspective.

Third trimester: Period of watchful waiting. Begins

to think of baby as separate being; may feel restless,
uneasy, and may feel that time of labor will never
come; remains self-centered and concentrates on
preparing place for baby. Fears for her well-being and
that of her baby.

Educational needs: Inadequate information Provide information and counseling.

Self-care measures and knowledge about the

following (discussed in Chapter 10 ):

Health promotion
Breast care
Hygiene
Rest
Exercise
Nutrition
Relief measures for common discomforts of
pregnancy
Danger signs in pregnancy (see Table 9–2 )

Sexual activity: Woman knows how pregnancy Lack of information about effects of Provide counseling.
affects sexual activity pregnancy and/or alternative positions
during sexual intercourse

Preparation for parenting: Appropriate preparation Lack of preparation (denial, failure to Counsel. If lack of preparation is due to
adjust to baby, unwanted child) inadequacy of information, provide
information.

Preparation for childbirth: Client aware of the Continued abuse of drugs and alcohol; If couple chooses particular technique, refer
following: denial of possible effect on self and baby to classes

1. Prepared childbirth techniques Encourage prenatal class attendance.

2. Normal processes and changes during childbirth Educate woman during visits based on
3. Problems that may occur as a result of drug and current physical status. Provide reading list
alcohol use and of smoking for more specific information.

Review danger signs that were presented on

initial visit.

Woman has met other physician or nurse-midwife Introduction of new individual at birth may Introduce woman to all members of group
who may be attending her birth in the absence of increase stress and anxiety for woman practice.
primary caregiver and partner

Impending labor: Client knows signs of impending Lack of information Provide appropriate teaching, stressing
labor: importance of seeking appropriate medical
assistance.

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 1. Uterine contractions that increase in frequency,
duration, and intensity
2. Bloody show
3. Expulsion of mucous plug
4. Rupture of membranes

Expectant Father/Partner

Psychologic status

First trimester: May express excitement over Increasing stress and anxiety; inability to Encourage partner to come to prenatal visits.
confirmation of pregnancy and of his virility; concerns establish communication; inability to Establish line of communication. Establish
move toward providing for financial needs; energetic; accept pregnancy diagnosis; withdrawal of trusting relationship.
may identify with some discomforts of pregnancy and support; abandonment of the mother
may even exhibit symptoms (couvade)

Second trimester: May feel more confident and be Counsel. Let expectant partner know that it
less concerned with financial matters; may have is normal for him to experience these
concerns about wife’s changing size and shape and feelings.
her increasing introspection

Third trimester: May have feelings of rivalry with Include expectant partner in pregnancy
fetus, especially during sexual activity; may make activities as he desires. Provide education,
changes in his physical appearance and exhibit more information, and support. Increasing
interest in himself; may become more energetic; numbers of expectant partners are
fantasizes about child but usually imagines older demonstrating desire to be involved in many
child; fears mutilation and death of woman and child or all aspects of prenatal care, education,
and preparation.

* Possible causes of alterations are identified in parentheses.

† This column provides guidelines for further assessment and initial intervention.

Focus Your Study

A complete history forms the basis of prenatal care and is reevaluated and updated as necessary throughout the
pregnancy.
The initial prenatal assessment is a careful and thorough physical examination and cultural and psychosocial
assessment designed to identify variations and potential risk factors.
Laboratory tests completed at the initial visit, such as a complete blood count, ABO and Rh typing, urinalysis/culture,
Pap smear, chlamydia culture, gonorrhea culture, rubella titer, and various blood screens (such as rapid plasma
reagin [RPR], HIV, and hepatitis B), provide information about the woman’s health during early pregnancy and also
help detect potential problems.
The estimated date of birth (EDB) can be calculated using Nägele’s rule. Using this approach, one begins with the
first day of the last menstrual period, subtracts 3 months, and adds 7 days. A “wheel” may also be used to calculate
the EDB.
Accuracy of the EDB may be evaluated by physical examination to assess uterine size, measurement of fundal
height, and ultrasound. Perception of quickening and auscultation of fetal heartbeat are also useful tools in
confirming the gestation of a pregnancy.
The diagonal conjugate is the distance from the lower posterior border of the symphysis pubis to the sacral
promontory. The obstetric conjugate is estimated by subtracting 1.5 to 2.0 cm (0.60 to 0.79 in.) from the length of
the diagonal conjugate.
As part of the assessment of the pelvic cavity (midpelvis), the prominence of the ischial spines is assessed, the
sacrosciatic notch and the length of the sacrospinous ligament are measured, and the shape of the pelvic side walls
is evaluated. ​Finally, the hollowness of the sacrum is determined.
The anteroposterior diameter of the pelvic outlet is determined, the mobility of the coccyx is assessed, the
suprapubic angle is estimated, and the contour of the pubic arch is evaluated to assess the adequacy of the pelvic
outlet.
The nurse begins evaluating the woman psychosocially during the initial prenatal assessment. This assessment
continues and is modified throughout the pregnancy.
Cultural and ethnic beliefs may strongly influence the ​woman’s attitudes and apparent cooperation with care during
pregnancy.
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 Clinical Reasoning in Action

Wendy Stodard, age 40, G3P0020, comes to the obstetrician’s office where you are working for a prenatal visit. Wendy
has experienced two spontaneous abortions followed by a D&C at 14 and 15 weeks’ gestation during the previous year.
She has a history of Chlamydia trachomatis infection 3 years ago, which was treated with azithromycin. She is at
10 weeks’ gestation. Wendy tells you that she is afraid of losing this pregnancy as she did previously. She says that she
has been experiencing some mild nausea, breast tenderness, and fatigue, which did not occur with her other
pregnancies. You assist the obstetrician with an ultrasound. The gestational sac is clearly seen, fetal heartbeat is
observed, and crown-to-rump measurements are consistent with gestational age of 10 weeks. The pelvic examination
demonstrates a closed cervix, and positive Goodell, Hegar, and Chadwick signs. You discuss with Wendy the signs of a
healthy pregnancy.

1. What signs are reassuring with this pregnancy?

2. What symptoms should be reported to the obstetrician immediately?
3. What is the frequency of antepartum visits?

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 References
American College of Obstetricians and Gynecologists (ACOG). (2011). Update on carrier screening for cystic fibrosis
(ACOG Committee Opinion No. 486). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). 2012. Noninvasive prenatal testing for fetal aneuploidy
(ACOG Committee Opinion No. 545). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2013a). Definition of term pregnancy (ACOG Committee
Opinion No. 579). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2013b). Gestational diabetes mellitus (ACOG Practice
Bulletin No. 137). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2013c). Medically indicated late-preterm and early-term
deliveries (ACOG Committee Opinion No. 560). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2013d). Ultrasound Exams (ACOG Patient Education
Pamphlet No. APO25). Washington, DC: Author.

American Diabetes Association (ADA). (2011). Position statement: Standards of medical care in diabetes—2011.
Diabetes Care, 34 (Suppl. 1), S11–S61.

Butt, K., & Lim, K. (2014). Determination of gestational age by ultrasound. Journal of Obstetrics and Gynaecology
Canada, 36 (2), 171–181.

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., … Sheffield, J. S. (2014).
Williams obstetrics (24th ed.). New York, NY: McGraw-Hill.

King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery (5th ed.).
Burlington, MA: Jones & Bartlett Learning.

Spong, C. Y. (2013). Defining “term” pregnancy: Recommendations from the defining “term” pregnancy workgroup.
Published online May 3, 2013. doi:10.1001/jama.2013.6235

VanDorsten, J. P., Dodson, W. C., Espeland, M. A., ​Grobman, W. A., Guise, J. M., Mercer, B. M., …Tita, A. T. (2013).
Diagnosing gestational diabetes mellitus: National Institutes of Health Consensus Development Conference
Statement. Retrieved from [Link]

Chapter 10 The Expectant Family: Needs and Care

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