CARE OF MOTHER, CHILD AND

ADOLESCENT (WELL CLIENTS)

NCM 107
By: KIM BRYAN DIEZ, RN,NZRN
FIDEL G. YONGQUE, RN, USARN
 DETERMINING
GRAVIDITY AND PARITY
 DEFINITION

• Gravidity is defined as the number of times that a

woman has been pregnant.
• Parity is defined as the number of times that she has
given birth to a fetus with a gestational age of 24
weeks or more, regardless of whether the child was
born alive or was still born
 DETERMINING THE GRAVIDITY AND PARITY

GRAVIDA – is the number of pregnancies regardless of duration or outcomes

A gravida (G) woman is:

- Pregnant (present) now
- Has been pregnant (past), irrespective of the outcome of pregnancy.

A nulligravida (G0) is a woman who:

- Is not pregnant now
- Has never been pregnant
 Principles in identifying parity

1.The number of pregnancies is counted and

not the number of fetuses.
• Example: Cynthia is pregnant for the first time and
is carrying twins. She is presently G1P0. At 37 – 38
weeks, Cynthia delivered to monozygotic twins
making her G1P1
 Principles in identifying parity

2. Abortion is not included in parity count because the

fetus is delivered before the age of viability (before 20
weeks). Parity will include all pregnancies beyond the age
of viability.
• Example: Sussie is pregnant for the second time. Her first
pregnancy 3 years ago ended in an abortion. Sussie is presently
G2P0. After delivery of a preterm or a full term baby, Sussie will be
designated G2P1. What is Sussie pregnancy ends in abortion at 12
weeks? Sussie will remain to be G2P0.
 Principles in identifying parity

3. Live birth or still birth is counted in parity

count.
• Whether the fetus is born alive or still, for as long as it has reached 20 weeks, it is
counted as one parity.
• Example: Josette is pregnant for the first time (G1P0). After 34 weeks, she delivered a 4 lb
baby boy with no signs of live (stillbirth). This makes Josette a primipara (G1P1)
• A nullipara is a woman who had not carried a pregnancy beyond 20 weeks or beyond the
period of abortion.
• A primipara is a woman who has completed one pregnancy to age of viability and
subsequently delivered the fetus whether alive or dead at birth.
 Principles in identifying parity

•A nullipara is a woman who had not carried a

pregnancy beyond 20 weeks or beyond the
period of abortion.
•A primipara is a woman who has completed one
pregnancy to age of viability and subsequently
delivered the fetus whether alive or dead at
birth.
 Principles in identifying parity

•A nullipara is a woman who had not carried a

pregnancy beyond 20 weeks or beyond the
period of abortion.
•A primipara is a woman who has completed one
pregnancy to age of viability and subsequently
delivered the fetus whether alive or dead at
birth.
 Principles in identifying parity

•A multipara is a woman who has carried 2or

more pregnancies to stage of viability and
subsequently born alive or dead.
•A grandmultipara is a woman who has had 6 or
more viable deliveries, whether, the fetuses
were alive or dead
 Principles in identifying parity

Ex. A nurse is taking the OB Hx of 22-year old, 4

month pregnant Mrs. Yale. Which of the following
statement correctly applies given this OB history of
Mrs. Yale: 1st pregnancy at age 15, complicated with
PIH, ended in the birth of SGA: second pregnancy at
age 18 resulted in the birth of twins, a boy and a girl,
third pregnancy at age 20 ended in the birth of a
stillborn with gestational age of 35 weeks.
 Principles in identifying parity

A.Mrs. Yale is a low-risk maternity client

B. Mrs. Yale is currently G4P2
C. Since a stillbirth is not included in parity count,
Mrs. Yale is G4P2
D. The presence of a twin is counted as 1 parity
making Mrs. Yale G4P3
 D. The history of adolescent
pregnancy, PIH, multiple
pregnancy, SGA baby and
Answer: stillbirth makes Mr Yale a
high risk maternity client. A
still birth and twinning is
given one parity count each,
making Mrs. Yale
First pregnancy

primigravida

2 or more pregnancy

multigravida

6 or more pregnancy

grand multigravida

PARITY OR PARA

total no. of pregnancies which the fetus reached the age of viability and
subsequently delivered whether dead or alive at birth.
 A woman who is described as “gravida 2, para 2” (sometimes
abbreviated to G2P2) has had two pregnancies and two deliveries
after 24 weeks.

A woman who is described as “gravida 2, para 0” (G2P0) has had

two pregnancies, neither of which survived to a gestational age of
24 weeks.
Example
If they are both currently pregnant again, these women would
have the obstetric resume of G3P2 and G3P0 respectively.

Sometimes a suffix is added to indicate the number of miscarriages

or terminations a woman has had. So if the second woman had
had two miscarriages, it would be annotated G3P0+2
 TERM RELATED TO PREGNANCY

• A nulliparous woman (nullip) has not given birth previously

(regardless of outcome.
• A primigravida is in her first pregnancy.
• A primiparous woman has given birth once. The term “primip” is
often used interchangeably with the primigravida, although
technically incorrect as a woman does not become primiparous
until she has delivered her baby.
• A multigravida has been pregnant more than once.
• A multiparous woman (multip) has give birth more than once.
 TERM RELATED TO PREGNANCY

• A grand multipara is a woman who has already delivered five or

more infants who have achieved a gestational ae of 24 weeks or
more, and such women are traditionally considered to be at higher
risk than the average subsequent pregnancies
• A grand multigravida has been pregnant five time or more.
• A great grand multipara has delivered seven or more infants
beyond 24 weeks’ gestation
• Multiple pregnancies present a problem: a multiple gestation
counts as a single event and a multiple birth should be interpreted
as single parous event.
 OBSTETRICAL SCORING

TPAL is one of the methods
to provide a quick overview
of a female’s obstetric
history. Two other methods
often used are gravida/para
and GPA.
In TPAL
• The T refers to term births
(after 36 weeks gestation)
• The P refers to premature
births
• The A refers to abortions
• The L refers to living children
 EXAMPLE TPAL

• A pregnant woman who carried one pregnancy to term with surviving

infant; carried one pregnancy to 35 weeks with surviving twins; carried
one pregnancy to 9 weeks as an ectopic (tubal) pregnancy; and has 3
living children would have a TPAL annotation
• T1, P1, A1,L3. This could be also be written as 1-1-1-3.
• Note, the “abortions” number refers to the total number of induced
abortions and miscarriages or ectopic pregnancies.
• The term “GTPAL” is used when the TPAL is prefixed with gravidity, and
“GTPALM” when GTPAL is followed by number of multiple pregnancies.
 T : number of full term infants born ( infants
born at 37 weeks or after)

P: number of preterm infants born ( infants

born before 37 weeks)

A: number of spontaneous miscarriage or

therapeutic abortions

L: number of living children

M: multiple pregnancies
 ESTIMATING EXPECTED DATE OF DELIVERY
(EDD)

Naegele’s Rule – the standard calculation is called

Nägele’s Rule. This was developed in 1850 by a doctor,
who determined that the average human pregnancy is
266 days from conception, or 280 days (40 weeks) from
the start of last menstrual period. To calculate this,
begin with the first day of your last period (LMP), add 7
days, the subtract 3 months.
 (LMP + 7 days) – 3 months =
Expected Date of Delivery
How are due Example: (April 1 + 7 – 3 months) =
dates January 8
calculated?
The “rule” does not take into account the fact
that many women are uncertain of he date of
their last menstrual period, not all women
have 28 day cycle, and not all women ovulate
on day 14 of their cycle.
Expected Date of Delivery (Naegel’s Rule)

EDD = (1st day of LMP) + 7 days- 3 months+ 1yr.

Example: LMP 10 June 2013 10 7 2013

+7 -3 + 1
______________
EDD 17 March 2014 17 4 2014
 Another Calculation

In 1990, researchers (mittendorf, et al) re-examined this

issue for modern American women. Results indicated that,
for first-time Causcasian moms, an average pregnancy last
274 days from conception (approximately 288 days from
the last menstrual period).
Mittendorf shows an average pregnancy is 269 days for
mothers who’ve given birth before. Non-Causcasian moms
have shorter pregnancies than Causcasian moms; for
example, African-American women average 266 days.
 Mittendorf’s Rule

Begin with the starting date of the last menstrual

period. Add 15 days for first time Causcasian mom, or
add 10 days if you’re non-white or this is not your first
baby. Then subtract 3 months.
(LMP + 15 days) – 3 months = Expected date of delivery
Ex: (April 1 + 15 days) – 3 months = January 16
 Estimating Gestational Age

If everyone had normal, regular periods, every 28 days,

and could remember exactly when their last period
was, and ovulation always occurred on day #14 of the
menstrual cycle, then gestational age determination
would be easy. These assumptions, however, are not
always the case. In real life, determining gestational age
can be challenging.
 MacDonald’s Rule

One way to approximate a pregnancy’s current gestational

age is to use a tape measure to determine the distance
from the pubic bone up over the top of the uterus to the
very top. That distance, measured in centimeters, is
approximately equal to the weeks of gestation, from about
mid-pregnancy until nearly the end of pregnancy
MacDonald’s Rule: Centimeter (cm) of fundal height =
weeks of gestation.
 MacDonalds Formula

Height of fundus divided by 4 = Age of Gestation

Measure in centimeters. The length from the symphysis
to the level of fundus
Example: Fundal Height: 14 centimeters
 MacDonalds Formula

Lunar months: Fundal height (centimeters) x 2.7

Weeks of pregnancy: Fundal height (cms) x 8/7
Lunar months: 14 cms x 2 = 28/7 = 4 months
Weeks pregnant: 14 cms x 8 = 112/7 = 16 weeks of
gestation
 Measuring Fundal Height with a Tape Measure

• To determine the gestation and growth of the fetus.

• To identify multiple pregnancies and complications of
pregnancy e.g. amniotic fluid disorders, hydatidiform
mole, and fetal growth disturbances.
• Symphyseal fundal height it to be performed at every
scheduled antenatal visit after 20 weeks gestation.
• Symphyseal fundal height must always be documented in
centimetres.
 PROCEDURE ADDITIONAL INFORMATION
1. Obtain maternal consent

2. Encourage the woman to empty her It has been demonstrated the fundal height
bladder if she has not done so in the last 30 can be 3 cms higher at 17 – 20 weeks
minutes. gestation if the woman has a full bladder
While not the preferred position for most
3. Position the woman in a supine position women, a supine position has been found
with her legs extended. to yield least variation in measurements.

Note: Consider placing a wedge under the
right buttock if the gravid uterus is of a size
likely to compromise maternal and/or fetal
circulation.
An enlarged uterus can compress the
inferior vena cava and the lover aorta
leading to maternal supine hypotension and
reduced utero-placental blood flow which
can cause fetal compromise.
 PROCEDURE ADDITIONAL INFORMATION
Warm hands minimize maternal discomfort
4. Ensure hands are clean and warm. and potential for inducing contraction of the
uterus.

5. Place the zero mark of the tape measure

There is no conclusive evidence to suggest
at the uppermost border of the symphysis
that either way of measuring is superior to
pubis or the uppermost
the other.
border of the uterine fundus.
 PROCEDURE ADDITIONAL INFORMATION

6. Run the tape measure along the midline To locate the fundus the hand is moved
of the woman’s abdomen to the uppermost down the abdomen below the
border of the uterine fundus or the xiphisternum until the curved upper border
uppermost border of the symphysis pubis. of the fundus is felt.

7.The distance is measured from the top of

the symphysis pubis to the depression in
front of the pad of the middle finger.

If there is a >2cm discrepancy the midwife

8. Document the distance in centimeters
should discuss this with the obstetrician or
and compare with the calculated gestation.
with the team.
 Bartholomew’s Rule of Fourths Fundus
• If a tape measure is unavailable, these
rough guidelines can be used.
• At 12 weeks, the uterus is just barely
palpable above the pubic bone, using
only an abdominal hand.
• At 16 weeks, the tope of the uterus is
½ way between the pubic bone and
the umbilicus.
• At 20 – 22 weeks, the top of the
uterus is right at the umbilicus.
• At full term, the top of the uterus is at
the level of the ribs (xyphoid process)
 • Johnson’s rule is used to estimate the weight
of the fetus in grams. To determine this, a
standard formula is used.
• Formula: fundic height in cm – n x k
• k is constant, it is always 155
Johnson’s Rule • n is 12 if the fetus is engaged
• It is 11 if the fetus is not yet engaged.
• Example A fundic height of 28 cm and the
fetus is not engaged.
• 28 cm – 11 x 155 = 17 x 155 – 2635 grams
Haase’s Rule Calculation of
- is to calculate fetal length in
centimeter for 6 – 10 month
the age of the the first 5 multiply by 5.
months, square
fetus on the the month.
basis of the
length
according to 2x2 = 4 cm
7 months x 5 =
35 cm
months of
gestation