Admission Assessment of the Pregnant Woman

Evelyn M. Hickson, RN, MSN, CNS, WCC

Objectives Identify potential complications of pregnancy

based on prenatal history, physical assessment and lab values.

Discuss the role of the perinatal nurse in screening, identifying, documenting and referring patients with history of domestic violence or substance use during pregnancy.

Discuss maternal infections, modes of treatment, and potential impact on the infant.

Review of Prenatal Records Review office reports, including

Obstetrical history Personal medical history Family history Social history

Note any areas of concern identified by the care provider

Prenatal Labs Blood type and antibody screen Rubella immunity GBS culture HSV HIV Hepatitis B VDRL/RPR Quad screen Glucose tolerance testing

OB History: Current Pregnancy Maternal age EDC

Dating criteria How early did she start prenatal care?

Gestation Current complications GTPAL

Gravidity Term births Preterm (<37 wk) births Abortions (elective, therapeutic or spontaneous) Living children

OB History: Multiparous Patients Length of previous labors, infant birth

weight, gestational age at delivery History of preterm labor or delivery Previous operative delivery Previous stillbirth History of postpartum hemorrhage or

postpartum depression

Social History Marital status or available family support CPS or other alerts Social/economic/educational concerns Physical/mental challenges Referral to social services Language barriers Religious or cultural practices

Prioritizing the Patient Interview

Sometimes the urgency of the situation dictates the order in which one proceeds with a patient interview, such as: Imminent delivery Unstable maternal condition

(Unconscious, bleeding, seizing, etc) Category 3 fetal tracing

Patient Interview Note the date and time of patient arrival Is your baby moving? Are you contracting? If so, when did they start

and how often are they occurring? Are you experiencing vaginal bleeding,

discharge, or leaking of fluid? Are you in pain? Orient the patient to the pain

scale and discuss her plans for pain management.

Send them to bathroom for UA.

Patient Interview (cont.) Current medications

Dose, route, last taken Allergies and reactions When the patient last ate or drank

(including what was eaten or drunk) Recent SVE Complications with current or previous

pregnancy

Is the patient experiencing… Nausea or vomiting Frequency or burning with urination Epigastric pain Headaches Visual disturbances

Physical Assessment Leopold’s Maneuvers EFM

Orient patient to monitors and basic strip interpretation

Physical Assessment Vital signs (full set) Urine dip Physical exam including: Edema DTRs and Clonus Breath sounds if patient presents with

respiratory symptoms SVE – unless contraindicated

Labor Assessment Time contractions started Frequency, duration, and regularity of

contractions Palpation of maternal abdomen during and

between contractions Fetal movement Pain assessment, including location and

type of pain

Herbs/Foods That Increase Uterine Activity

Bitter Melon Castor bean or castor oil Chamomile tea Cinnamon (spice tea) Garlic Ginger Goldenseal Pomegranate Red raspberry leaf tea

Suspected Rupture of Membranes Intercourse in last 12-24 hours Time possible SROM occurred Color, amount, and smell of fluid Testing of vaginal discharge for

presence of amniotic fluid

Substance Use and Abuse Warning signs of drug abuse:

Noncompliance with prenatal care – late entry or no prenatal care

Poor nutrition –due to adolescence, obesity, low socioeconomic status

Current or previous history of encounters with law enforcement Marital & family disputes

Intrapartum signs of substance abuse Unexplained IUGR 3rd trimester stillbirth Unexpected preterm birth Placental abruption in a woman without hypertensive disorders.

Informed consent for testing Social service consult, CPS, drug treatment

Domestic Violence Majority of abused women continue to be

victimized during pregnancy and may escalate. Most estimate rates between 4 –8%.

Child abuse occurs in 33 – 77% of families with adult abuse.

No single profile of an abused woman: all racial, economic, educational, religious, ethnic and social backgrounds.

Pregnancy and Domestic Violence

Signs of domestic violence in the pregnant patient include: unwanted pregnancy late entry into prenatal care missed appointments substance abuse or use poor weight gain and nutrition multiple, repeated somatic complaints.

Domestic Violence Screening Should be conducted in private, with

only the patient present “Because violence against women is so

common, I ask all of my patients do you have any reason to feel unsafe at home?”

Document patient statements accurately and quote them directly

Promptly Notify Care Provider if: Vaginal bleeding Acute abdominal pain Temperature of 100.4 F or higher Preterm labor Preterm rupture of membranes Hypertension Non-reassuring fetal heart rate pattern

SBAR Communication Best method to speak to providers Gives you a standard list of things you

need to be prepared to discuss with them

Be concise and factual Do not use “touchy-feely” language

SBAR Communication Situation

What is going on with the patient? Background

What is the clinical context? Assessment

What do I think the problem is? Recommendation

What would I do to correct it?

SBAR Guideline Prior to calling the provider:

Have I assessed the patient myself? Has the situation been discussed with a resource

nurse or preceptor? Have the following available when speaking:

Patient chart List of current medications, allergies, whether IV was

placed and labs drawn Most recent vital signs Reporting lab results: provide the date and time test was

done and results of previous labs for comparison

SBAR: Situation

What is the situation you are calling about? Identify self, unit, patient, room number State who the patient’s doctor has been for

the pregnancy Briefly state the problem, what is it, when it

happened or started, and how severe.

SBAR: Background Pertinent background information related

to the situation could include: Gestation, GTPAL, age, previously

identified risk factors List of current medications, allergies, labs Most recent vital signs Clinical information

SBAR: Assessment and Recommendation

What is your assessment of the situation? What is your recommendation or

expectation? Admission for labor Patient needs to be seen now Patient needs antibiotics for UTI, etc.

Document the care provider notification, orders received, changes in patient condition, and plan.

Guidelines for Communication with Physicians Using SBAR

Use the following according to provider preference. Direct page Call service During weekdays, the office directly On weekends and after hours during the week, home

phone Cell phone.

Wait no longer than 5 minutes between attempts. For emergent situations, use the appropriate chain of

command as needed to ensure safe patient care.

References Guidelines for Perinatal Care, (6th ed.)/AAP and

ACOG, 2005 Lowdermilk, D. and Perry, S. (2007). Maternity

and Women’s Health Care (9th ed.). St. Louis, MI: Mosby Elsevier.

Mattson, S. and Smith, J. (2004). Core Curriculum for Maternal-Newborn Nursing (3rd ed.). St. Louis, MI: Mosby Elsevier.

Simpson, K. and Creehan, P. (2010). Perinatal Nursing (3rd ed.). Philadelphia, PA: Lippincott.