Lesson

1
Assessment
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ack
Components of Health History
Intrave
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1. Demographic data (name, age, address, gender, marital status, educational level, occupation,
Oxytoci
religion and health insurance information)
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2. Chief concern: is the reason why a woman visits the health care setting. This is related to
Admini
thestratio
fact that she is or thinks she is pregnant.
3. Presentn health history

4. Past health history: woman’s past medical history including diseases that may cause
potential difficulty during pregnancy (e.g. heart disease, hypertension, diabetes, kidney
disease, thyroid disease, urinary tract infection, varicosities, tuberculosis, asthma, STIs
including Hepatitis B and C, herpes and HIV, childhood diseases and immunizations)

5. Family health history: illnesses that occur among woman’s relatives (hereditary diseases
like cardiovascular and renal disease, blood disorders cognitive impairment and congenital
anomalies or diseases inherited genetically)
6. Gynecologic history:
A. Menstrual history: age of menarche, length of menstrual cycle, duration and amount of
menstrual flow, any accompanying discomforts and menstrual pain.

 Menarche: is the first menstrual period

 Menopause: cessation of menstrual cycles
 Amenorrhea: absence of menstruation
 Dysmenorrhea: painful menstruation
 Menorrhagia: abnormally heavy menstrual flows
 Metrorrhagia: bleeding between menstrual periods
 Oligomenorrhea: scanty or very light menstruation

B. Perineal and Breast Self-Examination

 Perineal self-examination: inspecting the external genitalia monthly for
signs of infection or lesions
 Breast self-examination: monthly self-care routine

C. Past surgery: involves previous surgery on the reproductive tract which may
influence the ability of a woman to conceive and give birth

D. Reproductive planning

E. Sexual history
**Note: Abdominal examination is included

7. Obstetric history: includes previous pregnancy (when? type of delivery? outcome of birth?),
previous miscarriage or therapeutic abortions.

Classifying pregnancy status (OB Score)

GTPAL or GTPALM: provides information on woman’s history of pregnancy

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G: the number of times a woman has been pregnant, including the present pregnancy (Gravida
status)

P: the number of children over the age of viability that a woman has previously delivered (Para
status)

T: the number of full-term infants born at 37 weeks or after

P: the number of preterm infants born before 37 weeks

A: the number of spontaneous miscarriage or abortion

L: the number of living children

Definition of terms related to pregnancy:

Term Definition

Para Number of pregnancies that have reached viability, regardless of whether

the infants were born alive.

Gravida Woman who is or has been pregnant.

Primigravida Woman who is pregnant for the first time.

Primipara Woman who has given birth to one child past age of viability.

Multigravida Woman who has been pregnant previously.

Multipara Woman who has carried two or more pregnancies to viability.

Nulligravida Woman who has never been and is not currently pregnant.

Viability The ability of the fetus to survive in extra-uterine condition (20 weeks
gestation)
 Age of fetus ≥ 20-24 weeks
 Weighs at least 500g
 Length ≥ 18cm
Term pregnancy A pregnancy of 38 – 42 weeks

Preterm pregnancy It occurs before the end of 37 weeks of gestation

Postterm pregnancy A pregnancy that exceeds from 42 weeks

(Postmature or
postdate)
Datism
Abortion is the medical term for any interruption of pregnancy before a fetus is
viable

Miscarriage Early: Termination of pregnancy before 16th week

Late: Termination of pregnancy between 16th -24th weeks

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Naegele’s is a method used for calculating the estimated Expected Date of Delivery/Expected
Date of Confinement (EDD/EDC) based on Last Menstrual Period (LMP)

8. Psychosocial aspect- social support system

9. Laboratory result (CBC, Blood group and RH Factor, HCG, urinalysis, ultrasound)

10. Current medication or treatment

11. Functional health history/History of daily activity: information regarding

woman’s current nutrition, elimination, sleep, activity or exercise, personal habits, lifestyle,
recreation, and interpersonal interactions

12. Physical examination

A. Assessment of Body Systems
B. Height/Weight and Vital Signs:

Calculation of Body Mass Index:

BMI (Body Mass Index) = (weight per kg) / (Height per meter) ²

TOTAL WEIGHT GAIN DURING PREGNANCY (Body Mass Index – BMI)

*Institute of medicine (IOM) and National Research Council (NRC), 2009
(weight per kg/Height per meter2) Range of Total Weight Gain (lb) Single
Fetus
Underweight: BMI is less than 18.5 28-40
Normal weight: BMI is 18.5 to 24.9 25-25
Overweight: BMI is 25 to 29.9 15-25
Obese: BMI is 30 or more 11-20

Note:

Weight gain during 1st trimester: 0.8kg (1.5 lbs) per month ; 0.4 kg (1 lb) per week during the
last two trimesters (minimum weight gain 4.5 lbs, 12 lbs and 12 lbs for the trimester)

Normal weight gain during pregnancy is 11.3-15.8 kg (25 – 35 lbs)

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