CCT90 GR R0 UCe O25 Q 5 LQ CLG

MATERNAL AND NEWORN NURSING
CLINICAL MANUAL
Antenatal assessment
Antenatal assessment include
health assessment during the first
visit
History taking •
Physical examination •
Abdominal examination and fetal heart beats •
Diagnostic tests and laboratory tests •
History taking purposes:
Establishing rapport •
Gaining information about the women s •
physical and psychological health
Obtaining a basis for anticipating guidance for •
the pregnancy
History taking components
Demographic data •
Include age, name, address, tel.no, religion and
health insurance information
2 . Chief concern
Get information to confirm pregnancy date of the last •
menstrual period
Find the expected date of delivery as follow •
1 st day of LMP+7 days •
Ask if the pregnancy was planned •
Ask about danger signs of pregnancy such as bleeding, •
continuous headache, visual disturbance ,or swelling of the
hands and face.
Elicit information about signs of early pregnancy such as •
nausea, vomiting , breast changes , fatigue .
Ask about any discomfort of pregnancy such as constipation •
, backache, or frequent urination
3. Family profile
Ask about marital status •
Get to know her husband age , their education •
levels , and occupation (if it involves heavy
lifting or long standing ,or handing toxic
substances).
Gain information about her adaptation to •
pregnancy and changes in the psychological
status during pregnancy.
4.History of past illness
Ask about diseases that can pose potential •
difficulty during pregnancy such as kidney
diseases , heart diseases, rheumatic fever ,
sexually transmitted disease , diabetic , or asthma
Ask about any past surgical procedure •
Ask about any allergies , including drug •
sensitivities.
Find out whether a woman had childhood •
disease such as chickenpox, mumps, German
measles or , poliomyelitis.
5 . History of family illness
Ask about illness that occur frequently in the •
family and cause potential problems in the
pregnant woman or in the infant after birth,
like any inherited diseases or congenital
anomalies.
6.Gynecologic history
Obtain information about : •
Age of menarche (the first menstrual period ) •
Reproductive tract and breast problems •
Usual cycle including the interval , duration , amount of •
menstrual flow ,and any discomfort , when it occurs , how
long it last and what she does to relieve.
Past surgery on reproductive tract such as tubal surgery •
(after ectopic pregnancy ) uterine surgery , cesarean birth ,
frequent dilation and curettage.
Reproductive planning methods , if any , have been used. •
Stress in continence (incontinence of urine on laughing •
,coughing ,or running)
7.Obstetric history
Review the previous pregnancy briefly •

Ask about any previous miscarriage or abortion and •
whether she had any complication during or following
them
If the woman's blood type RH negative, ask if she •
received RH immune globulin (RHIG) after abortion or
previous births .
Ask if she has ever had a blood transfusion •
Determine number of times she has been pregnant , •
including the present pregnancy (GRAVIDA)
Determine number of children above the age of •
viability she has previously borne(Para)
A more comprehensive system for
Classify pregnancy status (GTPAL, GTPALM),greater •

detail on a woman's history:
G:Gravida •
T:the number of full_term infant born (born at 37 •
weeks or after)
P:the number of preterm infant born (born before 37 •
weeks )
A:the number of spontaneous or induced abortion •
L:the number of living children •
M:multiple •
Physical examination
A . INSPECTION •
1. baseline height/weight and vital sign measurement •
the approximate weight gain during pregnancy is 12kg •
,2 kg in the first weeks ,and 10 kg in the remaining 20
weeks
Overweight (more than 20 kg above the weight •
/height baseline)lead to an increased risk of gestational
diabetes , pregnancy induced hypertension
Underweight (less than 20kg below the weight /height •
baseline)also puts the pregnant woman at agreat risk.
2.Assessment of the system
Head and scalp: •
Check the hair for presence ,thickness dryness •
,and cleanliness .
The hair of a healthy woman's is shiny and •
Glossy.
Face •
The face is observed for skin color as pallor or •
pigmentation (chloasma). Hair growth speeds up
as a result of the overall increased metabolic
rate.
eyes
Observe for edema of the eyelid swollen optic •
disk
Report if the woman's sees spots before her eyes •
,diplopia , or poor vision .
Health women eyes are bright and clear . •
Also check the color of conjunctiva •
Nose •
The increase level of estrogen may cause nasal •
congestion or the appearance of swollen nasal
membranes
ears
The nasal stuffiness may lead to blocked Eustachian tubes and •
therefore a feeling of fullness in the ears
Sinuses •
They should feel non_tender, evaluate the sinuses ensure that •
clients report of headache is not sinus _related
Mouth , teeth , throat •
The gums may be slightly swollen and tender to the touch but not •
reddened .
Assess for cracked corners of the mouth (pregnant women prone to •
vitamin deficiency because of the rapid growth of the fetus )
Dryness ,or cyanosis of the lips should be watched •
Neck : observe for enlarged thyroid
gland and scars of previous
operation
Lymph node •
No palpable lymph node should be present •
Breasts •
The breasts should be observed for pregnancy changes •
The nipples should be drawn forward to see they are protractile •
Heart •
Many woman notice occasional palpitation during pregnancy •
teach them to rest or sleep on their side (left side is best )to help •
avoid this problem .
Lung •
Vital capacity of the lungs is not reduced. •
3.Abdominal examination
Inspection •
Skin changes such as linea nigra, striae gravid •
arum and scars of previous operation
The shape of the abdomen •
Fetal lie and position ex :transvers •
longitudinal ,oblique
Fetal movement are inspected as evidence of •
fetal life and position
palpation
Include fundal height to estimate the period of •
gestation
After 12th weeks gestation ,the uterus is palpable over •
the symphysis pubis as a firm globular sphere.
It reach the umbilicus at 20to 22weeks and the xiphoid •
at 36 weeks , and then returns to about 4cm below the
xiphoid due to lightening at 40 weeks.
Diagnosing the fetal lie and presentation •
To determine whether the fetus in a vertex or breach •
presentation
Determining whether the head engagement has •
occurred or it is still floating
Auscultation
Fetal heart rate sound is heard by sonicaid •

(Doppler pregnancy ) as early as (10th _12th
weeks) ) of pregnancy
The normal heart rate is 120-160beats / min •
5. estimating pelvic size •
6. pelvic examination •
Laboratory test
Complete blood picture(hb has to be repeated at the 36 •
weeks of pregnancy and every 4weeks if hb is <9g/dl)
Serological test for syphilis(VDRL) •
Blood typing including RH factor •
Screening for sickle cell anemia and thalassemia •
Antibody titers for rubella and hepatitis B •
HIV screening •
Random blood glucose (normally is 80 to 120 mg/100ml) •
An indirect coombs test for determination if RH antibodies •
are present in an RH negative woman
Urinalysis
It is a performed to test for proteinuria, •
glycosuria, and pyuria
Ultrasonography •
To assess the fetal growth and wellbeing •

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MATERNAL AND NEWORN NURSING

Review the previous pregnancy briefly •

Classify pregnancy status (GTPAL, GTPALM),greater •

Fetal heart rate sound is heard by sonicaid •

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