ASSESSMENT

IN

PREGNANCY

SUBMITTED BY:

Bonifacio P. Marilao Jr. – BSN1

SUBMITTED TO:

Mrs. Daphny Hatud RN, MAN

\
 OBJECTIVES

I.Definition of Terms:
a. Pregnancy
b. Antepartum
c. Gestation
d. Last Menstrual Period (LMP)
e. Age of Gestation (AOG)
f. Expected Date of Confinement (EDC)

II. Discuss the Prenatal Maternal Assessment

III. Identify Alteratives in Computing for AOG & EDC

a. McDonald’s Rule
b. Naegele’s Rule

IV. Compute AOG (Tinamban Style)

 
I. DEFINITION OF TERMS:

•Pregnancy
-(latingraviditas) is the carrying of one or moreoffspring, known as a fetus or embryo, inside the uterus of
afemale. In a pregnancy, there can be multiple gestations, as in thecase of twins or triplets. Human pregnancy is
the most studied of all mammalian pregnancies.
Pregnancy starts with fertilization of the ovum and ends with childbirth.
on average, it lasts approximately 280 days or 38 to 40 weeks.

•Antepartum
-refers to the medical & nursing caregiven to the woman between conception & onset of labor
•Gestation
is the period of time between conception and birth during which the fetus grows and develops inside
the mother's womb.

•Last Menstrual Period (LMP)

Refers to the first day of your last periodbefore conception occurred. It is used to calculate
the baby's duedate.

•Age of Gestation (AOG)

it is the time measured from the first day of the woman's last menstrual cycle to the current
date. It is measured in weeks. A normal pregnancy can range from 38 to 42 weeks.

•Expected date of Confinement (EDC)

reflecting the notion of themother being confined to a specific area for delivery. Is an
archaicterm for the estimated date a baby might be born. It is determinedbased on the first
day of a woman's last menstruation. Is alsocalled Estimated Date of Delivery or Estimated
Due Date (EDD).
II. PRENATAL MATERNAL ASSESSMENT
– The assessment focuses on the woman holistically by considering physical, cultural
and psychosocial factors that influence her health.
PROCEDURE NORMAL FINDINGS
Assess the following:
- Age Ideal childbearing years: 16 – 35
- Weight Average total weight gain: 25-35 lb
1st trimester: 2-4 lb
2nd trimester: 11 lb (1 lb/wk)
3rd trimester: 11 lb (1 lb/wk)
- Blood pressure Range of 90-139/60-89 mmHg
- Pulse 60- 90 bpm; may increase 10- 15
bpm higher than pregnant levels
- Behavior 1st trimester: tired, ambivalent
2nd trimester: introspective,
energetic
3rd trimester: restless, preparing for
baby labile moods
Observe skin color Linea nigra, striaegravidarum;
chloasma; spider nevi
Assess head and neck
- Nose Nasal stuffness, nosebleeds
- Eyes
- Neck Slightly enlargement of thyroid
Assess cardiovascular system
- Heart Short systolic blowing murmurs
- Blood volume Increases throughout pregnancy;
peaks at 30 – 40 weeks, reaching 30
– 50 % above pregnancy levels
Assess peripheral vascular system Late pregnancy : dependent edema,
ABNORMAL FINDINGS
- Younger than 16 or older
than 35; advanced maternal
age increases risk of genetic
abnormalities such as down
syndrome;
- increased risk to mother
and baby with age extremes.
- Prepregnant weight <100 or
>200 lb;
- Sudden gain of more than 2
lb/wk may be seen in
pregnancy-induced
hypertension(PIH);
- Weight loss or failure to
gain weight.
≥140/90 mmHg or increase mmHg
above baseline systolic or 15 mmHg
above baseline diastolic taken with
client in side lying position
- Increased levels are seen
with PIH
Irregularities; persistently <60 or
>100 bpm at rest.
Denial of pregnancy, withdrawal ,
depression, psychosis
Pale yellowing changes of skin as
seen with liver diseases
- Facial edema headache
Blurred vision and visual spots are
symptoms of PIH
Nodules or marked enlargement,
asymmetry thyroid gland as seen
with thyroid disease
Progressive dyspnea, palpitations,
markedly decreased activity
tolerance may be seen with cardiac
diseases.
Perineal varicosities; calf pain may

Assess respiratory system
Assess breasts
1. Examine the breasts
2. Don gloves
3. Assess the shape of each
nipple by putting your
thumb and index finger on
the areola and pressing
inward to express any
discharge.
- Note whether the nipple
protracts ( becomes erect)
or retracts ( inverts)
Assess gastrointestinal system
Assess genitourinary-reproductive
systems
Assess musculoskeletal system
Assess neurologic system
varicose veins, supine hypotension
Increased anteroposterior diameter,
thoracic breathing, slight
hyperventilation, shortness of
breath in late pregnancy
Increased size and nodularity,
tenderness, prominent
vascularization, darkening nipples
and areola, colostrum in third
trimester
- nipples normally protract
when stimulated.
Nausea and vomiting, increased
saliva, heartburn, bloating,
constipation
The urine may turn a brighter
yellow as a result of prenatal
vitamins.
Urinary frequency in 1st and 3rd
trimesters , increased pigmentation
of vulva and vagina, increased
vaginal discharge
Relaxation of pelvic joints:
“waddling” gait, increased lumbar
curve, backache, diastasis recti, leg
cramps
be related to deep vein thrombosis;
generalized edema; diminished
pedal pulses.
Dyspnea may be seen in patients
with cardiac disease and/ or lung
diseases such as asthma
Localized redness, localized pain
and warmth; erythemic streaks are
commonly seen with mastitis;
inverted nipples may cause
difficulty for breast-feeding infants.
Accessory breast tissue
( supernumerary nipple), most
commonly in the axilla and
secondary nipples on the nipple line
are abnormal.
Severe epigastric pain seen with
PIH; severe nausea and vomiting
may be seen during 1st trimester
with hyperemesis gravidarum.
Flank pain, dysuria, oliguria,
proteinuria, purulent vaginal
discharge , vaginal bleeding
Hyperactive reflexes, positive
clonus seen with PIH ; seizures
Prenatal Fetal assessment
Equipment needed:

- Bed or examination table

- Drape
- Pillow
- Paper centimeter/tape measure
- Fetoscope or Doppler

Inspection :

With the client supine and head slightly elevated on a pillow, inspect abdomen for shape and contour of fetus.

Palpation :

Using both hands, gently palpate the outline of the fetus and the top of the uterus (fundus) using the centimeter
tape, measure from top of the symphysis pubis to the top of the uterine fundus.

Uterine size is determined by internal pelvic exam on the initial prenatal visit, by palpation of less than 18 weeks,
and by fundal height in centimetres for subsequent visits. If the visit is late in pregnancy, it will include the internal
pelvic exam and fundal height.

PROCEDURE NORMAL ABNORMAL

Fundal height by centimeters :
1. Place the patient in supine
position.
2. Place the zero centimeter
mark of the tape measure at
the symphysis pubis in the
midline of the abdomen.
3. Palpate the top of the fundus
and pull tape measure to the
top
4. Note the centimeter mark
Accurate within 2 weeks until 36
weeks. Obesity or extremes in height
may alter findings
A 16-week uterus is between the
symphysis pubis and umbilicus
A 20-week uterus is at the umbilicus
(20 cm ) and from 18 to 32 weeks the
size is equal to the centimeter height
of the uterine fundus.
Lag in progression may indicate
problems with fetal development
and / or oligohydramnios commonly
seen with congenital abnormalities.
Sudden increase in fundal height
size may also indicate fetal
abnormalities such as congenital
anomalies.

After 32 weeks, although still used ,

this measurement is less accurate.

Auscultation :

With Doppler or fetoscope, listen to the fetal heartbeat. Locate fundus: begin listening halfway between the fundus
and the pubis. Work outward in widening circles until a beating sound is heard. Compare with the maternal pulse.
If different, count fetal heart rate for 1 full minute.

PROCEDURE NORMAL ABNORMAL

Auscultate Fetal Heart Rate (FHR) for the following:
1. Place the patient in the supine position.
2. Place Doppler or fetoscope on abdomen and move it around until FHR is heard.
3. Count the FHR for sufficient time to determine rate and absence of an irregularity ( optimally 1 minute ).

- Use Doppler to auscultate FHT prior to 20 weeks; afetoscope can be used after 20 weeks.
 - Location of fetal heart Generally geard in the midline area
between the symphysis pubis and
umbilicus.
- Presence Audible at 10 -12 weeks gestation Absence of fetal heart tones after the
with fetal Doppler ; audible at 15 – 20th week of gestation indicates
20 weeks gestation with fetoscope intra-uterine fetal demise
- Rate Very rapid initially; gradually slows <120 bpm; no change or decrease in
to 110 – 160 bpm (normal rate) at FHR with movement may indicate
term; increased rate with fetal fetal distress.
movement; during fetal sleep cycle,
FHR may be in the 110 – 120 range.
- Rhythm Regular A marked variance or variance of
<5 beats/min may indicate fetal
distress
DETERMINE FETAL PRESENTATION
Use Leopold’s maneuver:
1stmaneuver :
1. Place the patient in a supine position with the knees bent.
2. Stand to the patient’s right side facing her hand.
3. Keeping the fingers of your hand together, palpate the uterine fundus.
4. Determine which fetal part presents at the fundus.
2ndmaneuver:
1. Move both hands to the sides of the uterus.
2. Keep your left hand steady and palpate the patient’s abdomen with the right hand.
3. Determine the positions of the fetus’ back and small parts.
4. Keep your right hand steady and palpate the patient’s abdomen with your left hand.
3rdmaneuver:
1. Place your right hand above the symphysis pubis with your thumb on one side of the fetus’ presenting part
and your fingers on the other side.
2. Gently palpate the fetus’ presenting part.
3. Determine if the buttocks or the head is presenting part in the pelvis. ( this should confirm the findings of
the 1stmaneuver.)
th
4 maneuver:
1. Change your position so you are facing the patient’s feet.
2. Place your hands on each side of the uterus above the symphysis pubis and attempt to palpate the cephalic
prominence. This will assist you in determining the fetal lie ( long axis of the fetus in relationship to long
axis of mother and attitude (head flexed or extended).
NORMAL ABNORMAL
The fetus head is usually presenting part. It feels firm, Inability to determine fetal outline is abnormal.
round and smooth. The head can move freely when - Polyhydamnios and maternal obesity can lead to
palpated. If the baby is in breech position, the buttocks an inability to outline fetus.
feel soft and irregular. With palpation, the fetus’ back is
firm, smooth and continuous. The limbs are bumpy and
irregular.The long axis is vertical and fetal head is
flexed.

SYSTEMS (REVIEW) NORMAL FINDINGS CHANGES DURING

INTEGUMENTARY SYSTEM
•Skin is consistent withgeneric
backgroundand varies frompinkish
tan to ruddydark tan or from
lightto dark brown andmay have
yellow
oroliveovertones(dependingon race).
PREGNANCY
•Increased subdermal fat deposit
along withthickening of the skin due
to increase of estrogenlevels.
•Acne may develop or improved.
•Increased sweat and sebaceous
gland production.
 •Freckles and somebirthmarks may
benoted.
•Hair can be black,brown,
burgundy etc.and evenly
distributed,it covers the wholescalp
(no evidence of Alopecia), there are
noparasites and theamount is
variable. Itcan be thick or
thin,coarse or smooth andneither
brittle nor dry.
SENSORY SYSTEM •Eyeballs are alignednormally in
theirsockets with noprotrusion or
sunkenappearance. Looksmoist and
glossy.
•The iris appears flat, with a round
regularshape and evencoloration.
•Nose is Symmetric, nodeformities,
or skinlesions. Mucusa ispink, no
discharge, noseptal deviation
orperforation.
•Mouth has no lesions,bleeding
gums,toothache,
obstruction,epistaxis or allergy.
RESPIRATORY SYSTEM •Normally, the ratio of the AP
diameter to the transverse diameter
is approx. 1:2-5:7. In other words,
the normal adult is wider from side-
side than front to back.
•Bronchial breath sounds heard
over trachea; expiration is longer
than inspiration.
•Full symmetricexcursion;
thumbsnormally separate to 3-5 cm.
equal expansion.
•Fremitus is normallydecreased
over heartand breast tissue.
•Excessive oiliness/ dryness of the
scalp at six weeksof pregnancy.
•Spider nevi-acting red angiomas
occurring on theface, neck, chest,
arms, & legs due to
increaseestrogen level.
•Pigmentation increases in the
nipples, areolae,external genitalia
and the gluteal.
•Develop melasma, or chloasma
•Linanigra, or darkeningof the linea
alba.
•Nevi, circumscribed
•Pigmented areas of skin, maybe
stimulated togrow.
•Darkening of areola, nipples
axillae, umbilicus &perineum
•Skin tags,
molluscumfibrosumgravidarum,
maydevelop from epithelial
hyperplasia.
•Striae ( strech marks ) develops in
the breasts,and upper thighs
•Vascular changes reflected that can
include thedevelopment or
enlargement of spider
angiomas,hemangiomas,
varicosities.
•Facial hair may increase.
•Corneal thickening and edema.
•Nasal stuffiness, snoring,
congestion andepistaxis,.
•Impaired hearing or fullness in the
ears anddecreased sense of smell.
•Increased vascularity,
edematousand bleedinggums.
•Ptayalism, excessive secretion of
saliva
•Vocal changes or cough.
•Increased oxygen consumption and
carbon dioxide secretion.
•Diaphragm elevates approximately
4cm
•Movement of the diaphragm
increases.
•Respiratory effort is
diaphragmatic.
•Thoracic cage relaxes and expands
by 5-7cm.
•Tidal volume increases by 30-40%
•Physiological changes, an increased
respiratory rate, hyperventilation,

CARDIOVASCULAR SYSTEM •There are no pulsations palpable
over aortic and pulmonic areas.
Apical has the loudest sound and
should be 60-80bpm. No murmurs
should be heard.
GASTROINTESTINAL SYSTEM •The surface is uniform in color and
in pigmentation. Flawless, no scars
- Abdomen present. No striae /stretch marks
- Esophagus present. Few veins may be visible
- Stomach and intestines normally.
- Gallbladder •Umbilicus is in the midline and
- Liver inverted with no sign
of discoloration or hernia.
•Normally shaped from flat to
rounded; hair distribution is
diamond shape in males and
inverted triangular shape in
females. Tympany is usually
predominating because of air in the
stomach and intestines.
•The liver is not inflamed; not
painful to touch and may feel like a
firm rectangular ridge. Often it is
not palpable and you feelnothing
firm.
or shortness of breath.
•Increase in Plasma, blood volume
increases by 30-50%.
•The mother’s heart lies more
horizontally and shifts upward and
to the left along with the apical
impulse.
•Heart rate increases by 10-15 bpm.
•Increased breast vascularization
may lead to contiuous murmur
“mammary soufflé”.
•Supine hypotension
•Systolic pressure is not significantly
whereas the diastolic pressure may
lower by 5mmHg.
•Experiencing dependent edema due
to peripheral vasodilation and
decreased vascular resistance.
•Swelling is most commonly seen in
the feet but can also occur in the
hands and face.
•Decreased tone and motility
•Decreased bowel sound
•Increased emptying time for the
stomach and intestines.
•Increased flatulence and
constipation
•Indigestion due to relaxation of
esophageal sphincter, substituent
reflux and slowed gastric emptying.
•Nausea and vomiting are common
•Experience a separation of the
rectus muscle of the abdominal wall,
known as diastasis recti.
•Peristalsis of the esophagus
decreases and relaxes the lower
esophageal sphincter.
•Bowel sound may not be evident in
the four normal quadrants
•Appendix may be found as high as
the right flank
•Changes in the tone of the stomach
delayed
•Emptying may contribute the early
nausea and vomiting.
•Acid production in the stomach is
decreased
•Effect of progesterone on smooth
muscle also decreases the tone and
motility
•The cholesterol in the bile of the
pregnant woman is more likely to
crystallize.
•Physically displaced by the
enlarginguterus.
•Nausea and vomiting, increased

URINARY SYSTEM
MUSCULOSKELETAL SYSTEM •Head position is centered in the
midline, and the accessory muscles
should be symmetrical.
• The torso and head are upright;
walking is initiated in one smooth
rhythmic fashion.
•Muscle shape maybe accentuated
in certain body areas such as limbs
and upper torso but should be
symmetrical and it should feel
smooth and firm.
•There is no involuntary muscle
movement.
•Normal muscle strength allows for
complete voluntary range of joint
motion against both gravity and
moderate to full resistance.
NEUROLOGICAL SYSTEM •No unusual frequent or severe
headaches, no head injury, dizziness
or vertigo, seizures or tremors.
•No weakness, numbness, or tingling
or difficulty in speaking.
saliva, heartburn, bloating,
constipation
•Glomerular filtration rate GFR
increase by approximately 50% and
reabsorption rate of various
chemical especially sodium and
water changes
•Urinary frequency usually
increases in the 1sttrimester.
•Glycosuria glucose in the urine is
common in pregnancy.
•There is also an increase loss of
amino acid they may show as
protienuria on a urine dipstick
•Dilation of ureters and renal
pelvises, decreased in bladder tone,
and short female urethra plays the
pregnant woman at risk for urinary
tract infection.
•Nocturia or excessive night time
urination, may disrupt the pregnant
woman’s sleep pattern.
•The thyroid gland may increase in
size after approximately 12 weeks of
gestation (although studies are
conflicting as t o whether or not
there is and increase) related to the
increase in vascularity. This may
result in a shift in thyroid tests.
•Widening of smphysis pubis at
approximately 28-32 because of
hormones relaxin and progesterone
affects all joints in the
pregnant woman’s body
•Increased pelvic mobility to
accommodate vaginal delivery
•Developing lordosis of the lumbar
spine that would keeps the center of
gravity over the legs
•Leg weakness
•Developing of muscle cramps,
particularly in the calves, Thighs
and buttocks especially at night
•Increase of shoe size as much as full
size as pregnancy progresses
because of edema and relaxation
foot joints.
•Increased of fat deposits
throughout the body.
•Headaches
•Numbness and tingling
•Seizure activity with no prior
history may indicate the
development eclampsia, or seizures
associated with pregnancy- induced
hypertension.

REPRODUCTIVE ORGAN •The skin over the mons pubis
should be clear except for nevi and
normal hair distribution.
•Labia majora and minora should
appear symmetrical with a smooth
to somewhat wrinkled, unbroken,
slightly pigmented surface.
BREASTS •There should be no ecchymosis
cyst, excoriation, nodules, swelling,
rash or lesions.
•Clitoris is 2cm in length and .5cm I
ndiameter without lesions. The
urethral opening is slitlike in
appearance and midline; it is free
of discharge, swelling or redness
and is about the size of a pea.
Normal vaginal discharge is clear
to white and free of foul odor.
ANUS AND RECTUM •Common to have as light
asymmetry in size; often the left
breast is slightly larger than the
right.
•The anal mucosa is deeply
pigmented, coarse, moist and
hairless. It should be free of lesions,
inflammation, rashes, masses or
additional openings.
•The anal opening should be closed
and no leakage of fecesormucus
from the anus.
•The rectum shouldaccommodate
theindex finger, thereshould be
goodsphincter tone at rest with
bearing down.
HEMATOLOGICAL SYSTEM
•Dizziness and lightheadedness may
due to the fetus pressure on the vena
cava.
•Lapses of memory and etiology is
poorly understood
•Enlarging uterus
•The round and broad ligaments
elongate to accommodate the
growing fetus and may cause the
patient lower quadrant pain
•Decrease fundal height ( lightening)
it is due to the descent of the
presenting of the fetal part into the
pelvis
•Cervix experiences increases
vascularity and increased friability
or susceptibility to bleeding
•Vaginal discharge increases and is
typically of a white consistency.
•Breast changes may include
enlargement, tingling and
tenderness secondary to hormonal
changes.
•The areolae may darken. The
nipples maybe come darker and
more erect.
•Colustrum, a thick, yellow
discharge known as early breast
milk, maybe secreted as early as the
2nd trimester.
•Veins in the breast may become
more apparent and blue as they
become engorged from increased
vascularization.
•Decrease gas through intestinal
tract tone and mobility
•Development of hemorrhoids
•Increase white blood cells
•Increase total red blood cells
volume
•Increase plasma volume
•Decrease number and increase size
of platelets
 •Increase fibrinogen and clotting
factors VI-X.

ENDOCRINE SYSTEM •Increase oxygen consumption and

to fetal metabolic demands may
often lead to feeling of  warmth and
hest tolerance

RENAL SYSTEM •Increase glumerular filtration rate

and renal plasma flow
•Increase urinary output and
decreases edema
•The woman’s kidneys must manage
the increase metabolic and
circulatory demands of the,
maternal body and the excretion of
fetal waste product.
III. IDENTIFY ALTERNATIVES IN COMPUTING FOR AOG &EDC
A. NAEGELE’S RULE (Expected date of confinement)

Formula:

(1st day of LMP) + 7 days – 3 months + 1 year

Example: LMP: 15August, 2014

15 08 14
+7 +3 +1
22 11 15 = Thus, EDC: 22ndof November 2015

B.MCDONALD’S RULE( Age of Gestation)

- estimation using the fundic height
- fundal height (measured from symphisis pubis to top of uterus)
- used to app. Fetal age (in weeks)
- application from 22-34 weeks age of gestation

Formula:
# of cm x 8/7 = wks gestation
# of cm x 2/7 = duration of pregnancy in months

Note: inaccurate in 3rd trimester 

IV. COMPUTATION OF AGE OF GESTATION (AOG)
(TINAMBAN STYLE)

For Example:Last menstrual period (LMP): April 5, 2014

Assessment date: January 12, 2015

LMP = 30 (days of themonth of april) - 5 (day) = 25

AOG:
May 31
June 30 40 r. 2
July 31 7 282
Aug 31 28
Sept 30 02
Oct 31
Nov 30
Dec 31
Jan 12

282 days

AOG = 40 WEEKS AND 2 DAYS