PRENATAL ASSESSMENT

Health assessment during 1st prenatal visit

- Health history
- Obstetric/gynecologic history
- Physical examination

Obstetric and Gynecologic History

I. Biographic Data
a. Patient’s name
b. Address
c. DOB
d. Occupation
e. Source and reliability of information
II. Client profile
a. Age
b. Sex
c. Race/ethnic
d. Marital status
III. Current pregnancy – obstetric history
a. First day of LNMP – Are you sure of the dates or uncertain?
b. Do your cycles normally occur every 28 days, or do your cycles tend to be longer?
i. Average menstrual cycle is about 28 days. This means that about 28 days pass
between the first day of your period and the first day of your next period.
ii. Menstrual flow may occur every 21 to 35 days and last 2 to 7 days.
 c. Presence of CRAMPING, BLEEDING, or SPOTTING since LMP
d. Woman’s opinion about the time when conception occurred and when infant is due.
e. Woman’s attitude toward pregnancy. (Is this pregnancy planned? Wanted?)
f. Results of pregnancy tests, if completed
g. Any discomforts since LMP such as nausea, vomiting, urinary frequency, fatigue, or
breast tenderness  PROBABLE SIGNS OF PREGNANCY

IV. Past Pregnancies – Gravidity and Parity of Pregnancy – Obstetric Score

a. Gravida (G) – number of pregnancies
b. Para (P) – number of completed pregnancies, 20 weeks or more
c. Preterm (P) – number of preterm delivered, 20-37 weeks
d. Term (T) – number of full terms delivered, 37-42 weeks
e. Abortion (A) – number of abortions, SPONTANEOUS and INDUCED
f. Living (L) – number of living children
g. Multiple pregnancies (M) – number of multiple pregnancies (ex. twins)
h. Two Digit System – Gravida/Para or G/P
i. Ms. Cherry is pregnant for the first time (primigravida) and has not carried
pregnancy for 20 weeks or more (nullipara)  G1 P0 or Gravida 1 Para 0
ii. Ms. Juana 22 y/o is 6 months pregnant; she had one spontaneous abortion and
has a daughter born 38 weeks of gestation.  G3 P1 or 3x pregnant, 1
completed
i. Five Digit System – Gravida/Para/Term/Abortion/Living or GTPAL
i. Mrs. Castro is 7 months pregnancy. She had one spontaneous abortion and one
ectopic pregnancy; she has a son born 39 weeks and a daughter born at 36
weeks.
 Gravida – 5
 Term – 1 (son born at 39 weeks)
 Preterm – 1 (daughter born at 36 weeks)
 Abortion – 2 (1 spontaneous + 1 ectopic pregnancy)
 Living children – 2 (son and daughter)
 G5 T1 P1 A2 L2
ii. Mrs. Cruz has one child born at 38 weeks of gestation and one stillborn of 24
weeks and pregnant now of twins at 32 weeks of gestation.
 Gravida – G3
 Term (pregnancy delivered) – T1 (child born at 38 weeks)
 Preterm (pregnancy delivered) – P1 (stillborn at 24 weeks)
 Abortion – A0
 Living children – L1
 G3 T1 P1 A0 L1
j. When trying to determine the Parity, keep the following in mind:
i. The count includes babies born alive or stillborn at 20 weeks gestation or
greater.
ii. Multiple babies  just like with gravidity, we’re not counting the number of
babies born/birthed. Therefore, if a woman completes a pregnancy at 20 weeks
 gestation or greater with twins, triplets, quadruplets, etc., the GRAVIDA/PARITY
is just ONE.

IV. Past Pregnancies (OB HISTORY)

a. History of previous pregnancies, length of pregnancy, length of labor and birth, type of
birth (vaginal, forceps, vacuum birth, cesarean), type of anesthesia used if any
(EPIDURAL), woman’s perception of the experience, and complication (antepartal,
intrapartal, and postpartal).
b. Neonatal status of previous children: APGAR scores, birth weights, general
development, complications, and feeding patterns (breast milk or formula).
c. Loss of a child: miscarriage, elective, or medically indicated abortion, stillbirth, neonatal
death, relinquishment, or death after neonatal period. What was the experience like for
her? What coping skills helped? How did her partner, if involved, respond?
d. If Rh negative, was medication received after birth to prevent sensitization?
e. Prenatal education classes and resources (books)
V. Gynecologic History
a. Date of last pap smear; any history of abnormal pap smear
b. Previous infections: vaginal, cervical, tubal, or sexually transmitted
c. Previous surgery
d. Age of menarche
e. Regularity, frequency, and duration of menstrual flow
f. History of dysmenorrhea
g. Sexual history
h. Contraceptive history: if birth control pills were used, did pregnancy occur immediately
following cessation of pills? If not, how long after?
VI. Current Medical History
a. Weight
b. Blood type and Rh factor, if known
c. General health, including nutrition, normal dietary practices, and regular exercise
program (type, frequency, and duration)
d. Any medications presently being taken (including prescription, nonprescription,
homeopathic, or herbal) or taken since the onset of pregnancy
e. Previous or present use of alcohol, tobacco, or caffeine: ask specifically about the
amounts of tea, colas, or chocolate consumed each day
f. Illicit drug use or abuse: ask about specific drugs such as cocaine, crack, and marijuana
g. Drug allergies and other allergies
h. Potential teratogenic insults to this pregnancy such as viral infections, medications, x-ray
examinations, surgery, or cats in home (possible sources of toxoplasmosis)
i. Presence of disease conditions such as diabetes or renal problems, or thyroid disorder
j. Record immunizations (especially rubella)
k. Presence of abnormal symptoms
VII. Past Medical History
a. Childhood disease
b. Past treatment for any disease condition
 c. Surgical procedures
d. Presence of bleeding disorders or tendencies (has she received blood transfusions?)

VIII. Family Medical History

a. Presence of diabetes, cardiovascular disease, cancer, hypertension, hematologic
disorders, tuberculosis, or preeclampsia-eclampsia
b. Occurrence of multiple births
c. History of congenital disease or deformities
d. Occurrence of cesarean birth and cause, if known
IX. Religious, Spiritual, and Cultural History
a. Does the woman wish to specify religious preference on her chart? Does she have any
religious beliefs or practices that might influence her health or that of her child
b. What practices are important to maintain her spiritual well-being?
c. Might practices in her culture or that of her partner influence her care or that of her
child?
X. Occupational History
a. Occupation
b. Physical demands
c. Exposure to chemicals or other harmful substances
d. Opportunity for regular meals and breaks for nutritious snacks
e. Provision for maternity or family leave
XI. Partner’s History
a. Presence of genetic conditions or diseases
b. Age
c. Significant health problems
d. Previous or present alcohol intake, drug use, or tobacco use
e. Blood type and Rh factor
f. Occupation
g. Educational level
h. Attitude toward the pregnancy
XII. Personal Information about the Woman
a. Housing
b. Economic level
c. Acceptance of pregnancy
d. Any history of emotional or physical deprivation or abuse of herself or children or any
abuse in her current relationship
e. History of emotional problems
f. Support systems available to her
g. Personal preferences about the birth
h. Feeding preference for the baby
EXPECTED DATE OF DELIVERY
 Standard method used to predict the length of pregnancy
 Common practices is to estimate the EDD on the basis of the first day of the LNMP
 In a regular 28-day cycle, the ovulation occurs approximately 2 weeks after the beginning of
menstruation

Naegele’s Rule – Expected Date of Delivery (EDD)

 Situation: Mrs. Ma came in for prenatal check-up today December 2, 2022. LMP was last
October 19, 2022. Compute for EDD
 STEP 1 – Determine the first day of LMP and numerical value of each month
Month Day Year
October 19, 2022 (LMP)
10 19 2022
 STEP 2 – SUBTRACT 3 months from the date
10 19 2022
-3
-----------------------------------
7  JULY
 STEP 3 – ADD 7 DAYS to the date of LMP, ADD 1 to the year
10 19 2022
-3 +7 +1
-------------------------------
7 26 2023  EDD is JULY 26, 2023

ALTERNATIVELY:

 For January to March LMPs – just ADD 9 MONTHS, ADD 7 DAYS, and RETAIN YEAR
Ex. LMP is January 18, 2022
1 18 2022
+9 +7 ------
------------------------------
10 25 2022  EDD is October 25, 2022
 For April to December LMPs – just use the same formula (-3months, +7days, +1year)
Ex. LMP is June 12, 2022
6 12 2022
-3 +7 +1
-----------------------------
3 19 2023  EDD is March 19, 2023
LEOPOLD’S MANEUVER
- A systematic method for determining the:
o PRESENTATION, POSITION, and LIE OF THE FETUS using FOUR SPECIFIC STEPS
- This method involves inspection and palpation of the maternal abdomen as a screening
assessment for malpresentation.
- Provides valuable information about the location and presentation of the fetus
- Usually done before assessing the fetal heart tone

Each Maneuver answers a question:

 What FETAL PART is in the FUNDUS (top of the uterus)?

o Is it the head? Or is it the buttock?
 On which MATERNAL SIDE is the FETAL BACK located?
o Right side? Or left side?
o Fetal heart tones are best auscultated through the back of the fetus
 What is the PRESENTING PART? (Towards the symphysis pubis)
o Head?
o Buttocks?
o Foot?
o Back?
 Is the fetal head FLEXED and ENGAGED in the pelvis?
o Engaged – means largest part of the had has entered the pelvis

 1st Maneuver – Fetal Presentation (cephalic or breech in the fundus)

 2nd Maneuver – Fetal Lie/Position (fetal back on right/left; occiput anterior/posterior;
transverse)
 3rd Maneuver – Fetal Engagement (engaged or floating)
 4th Maneuver – Fetal Attitude (vertex/flexed or face/extended)

ASSESSMENT
STEPS RATIONALE
1. Conduct a comprehensive OB health history Serves as a baseline data for the client’s present
and future conditions
2. Assess the client’s maternal condition including Aids in the detection of possible problems and/or
signs and symptoms related to pregnancy. complications related to pregnancy.
PLANNING
1. Ask the client to empty her bladder if she has It decreases discomfort of a full bladder during
not done so recently. palpation and improves ability to feel fetal parts
in the suprapubic area.
2. Have her lie on her back with knees slightly Knee flexion helps the woman relax her
flexed. abdominal muscles to enhance palpation.
a. Place a small pillow or folded towel under one Uterine displacement prevents aortocaval
hip. compression, which could reduce blood flow to
the placenta.

IMPLEMENTATION
STEPS
1. Explain the procedure to the client and the
rationale for each step as it is performed. Tell her
what is found at each step.
2. Wash hands with warm water. Wear gloves if
contact with secretions is likely.
RATIONALE
Gives information, teaches the woman, and
reassures her when assessment findings are
normal.
Prevents transmission of microorganisms. Warm
hands are more comfortable during palpation
and prevent tensing of abdominal muscles.

STEPS RATIONALE FINDINGS

3. Perform the FIRST  Distinguishes between a  BREECH is softer and more
MANEUVER (FETAL cephalic and breech irregular in shape than
PRESENTATION) presentation. head.
a. Stand at the foot of the  CEPHALIC PRESENTATION –  Moving the breech also
patient, facing her, and placing sacrum is in fundus. moves the fetal trunk.
both hands flat on her  BREECH PRESENTATION –  HEAD is harder and has a
abdomen. head is in fundus round, uniform shape;
moves independently.
b. Palpate the superior surface  The head can be moved
of the fundus. without moving the entire
Determine consistency, shape, fetal trunk.
and mobility.

STEPS RATIONALE FINDINGS

4. Perform the SECOND  Determines on which side of  FETAL BACK is a firm,
MANEUVER (FETAL LIE the uterus is the BACK and smooth, convex surface
/POSITION) on which side are the fetal  FETAL ARMS & LEGS feel
a. Face the patient and place ARMS and LEGS (“small nodular
and palms of each hand on parts”).  Fetus often moves them
either side of the abdomen.
b. Palpate the sides of the
uterus.
Hold the left hand stationary on
the left side of the uterus while
the right hand palpates the
opposite side of the uterus from
top to bottom.
Then hold the right hand steady
and repeat palpation using the
left hand on the left side.
 Is the fetal position on the during palpation
LEFT, or RIGHT?
 OCCIPUT – back of fetal skull
or the occipital bone
a. OCCIPUT ANTERIOR – back
of fetal head is closes to the
mother’s front.
b. OCCIPUT POSTERIOR – back
of fetal head is closest to
mother’s back.
 TRANSVERSE – halfway
between anterior and
posterior.

STEPS RATIONALE FINDINGS

5. Perform the THIRD  Confirms the presentation  If breech was palpated in
MANEUVER (FETAL determined in the first the fundus – expect a hard,
ENGAGEMENT) maneuver. rounded head in this area.
a. Gently grasp the lower  ENGAGED – widest diameter  If the presenting part is NOT
portion of the abdomen just at or below a zero station in ENGAGED – the grasping
above the symphysis pubis the maternal pelvis movement of the fingers
between the thumb and index moves it upward in the
finger and try to press the uterus; movable, floating
thumb and finger together.  ENGAGED – presenting part
is immovable.
Determine any movement  FLOATING – presenting part
whether the part is FIRM or can be gently pushed back
SOFT. and forth; not engaged.
6. OMIT THE FOURTH  It is PERFORMED ONLY IN
MANEUVER IF THE FETUS IS IN CEPHALIC PRESENTATIONS
THE BREECH PRESENTATION. to determine whether fetal
head is fixed.
  In short legs, buttocks are on
the pelvic cavity.

STEPS RATIONALE
7. Perform the FOURTH MANEUVER (FETAL  Determines whether the head is flexed
ATTITUDE) (vertex) or extended (face).
a. Stand on the side of the mother’s abdomen,
fronting the feet apart and grasp with both palms
the lower abdomen.
Try to determine the DEGREE OF FLEXION of the
head.
b. Place the fingers on both sides of the uterus  Vertex presentation is normal.
approximately 2 inches above the inguinal  If the head is flexed, the cephalic
ligaments, pressing downward and inward in the prominence (forehead) is felt on the
direction of the birth canal. opposite side from the fetal back.
Allow fingers to be carried downward.  If the head is extended, the cephalic
prominence (occiput) is felt on the same
side as the fetal back.

FACE – cephalic prominence is on the opposite

side as the small parts (arms and legs).

VERTEX – cephalic prominence is on the same

side of the small parts (arms and legs).
EVALUATION
STEPS RATIONALE
1. Document the findings Observes legal imperatives in record keeping.
a. Document the finding in proper sequence from
the first to fourth maneuver.