Pre-conception / Inter-conception Care
Training Curriculum 2
Risk Assessment includes obtaining the following data:
- Demographic information
- Gynecologic history, including the date of the last menstrual period (LMP)
- History of contraceptive use
- Obstetric history
- Estimated day of delivery (EDD) determined by the last menstrual period if known. If the date is unknown or a size-date discrepancy exists, an ultrasound examination should be performed before 20 weeks.
- History of current pregnancy
- Accurately dating pregnancy
- Medical/surgical history
- Genetic history
- History of dental care
- Social history/Lifestyle behaviors
- Environmental exposures
- Pharmacologic history
- Nutritional assessment including pregnancy weight and body mass index (BMI)
- Psycho-social assessment
- Physical examination
- Employment history
- Financial planning
The assessment process begins with the initial Prenatal visit, and will be more effective if a preconception visit occurred. It is on-going and ideally starts with the initial visit which should occur between 6-8weeks of gestation. At the initial prenatal visit the patient=s database is established, if not prior to conception, and involves assessment or collecting physical, historical and laboratory data from which a plan of care is developed and followed throughout the course of the pregnancy. Historical data include the following:
The age of the mother is an example of a characteristic that is associated with both medical risk (because pregnancy at the extremes of the reproductive age span can have specific physiological consequences) and psycho-social risk. Marital status of the mother may provide a possible indicator of support if she is single, separated, divorced, or has no significant other to assist throughout her pregnancy and postpartum. It will indicate whether there is a need to plan for child care for the baby and some occasional respite care for the mother.
Assessment of income and financial resources for pregnancy will allow the provider to assess the need for financial assistance through Medicaid, or other funding. All clients should be assessed for Medicaid eligibility via the Medicaid Presumptive Eligibility process. Education assessment is useful for at least two reasons. The client may need assistance to either continue schooling if an adolescent, or in pursuit of a G.E.D. if she dropped out of school. Education assessment can also offer insight into possible ability to comprehend information supplied by the provider. It is important to ascertain from the patient what her housing situation is: homeless, evicted, living in a shelter, etc.
Menstrual history includes premenstrual syndrome, dysmenorrhea, fibroid tumors, irregular bleeding, abnormal Pap smears, pelvic surgeries or interventions; last normal menstrual period (LNMP), and Diethylstilbestrol (DES) exposure. The number of weeks that have elapsed between the first day of the LNMP (not the presumed time of conception) and the date of delivery is the means to calculate gestational age, regardless of whether the gestation results in a live birth or a fetal death.
Information should include whether this pregnancy was planned and is wanted, what contraception method was used, the current sexual relationship, is it monogamous, and if not the number of partners involved.
Past Obstetric History
This topic covers prior pregnancies, previous intrauterine growth retardation (IUGR), infant/pre-term birth, high parity, birth interval of less than two years, previous hemorrhage, stillborn or neonate death, sudden infant death syndrome (SIDS). Any of these would indicate greater risk factors for the client.
Ascertain whether the client has experienced any chronic diseases such as diabetes, hypertension, anemia, and what prescription or over the counter medications were or are being used. Gather information on infections such as hepatitis, toxoplasmosis, group B streptococcus infections, allergies.
Trauma, surgical procedures, blood transfusions. Learn whether satisfactory resolution was achieved on any of these topics.
Is there a record of repeated spontaneous abortions, chromosomal and other congenital abnormalities, hemoglobinopathies such as sickle cell anemia. Has the client, spouse or family been exposed to radiation or other toxic substance exposure? Have there been multiple births? Is there a family history of chronic diseases (diabetes, hypertension, anemia, etc.
Life Style Behaviors
This section should assess the client=s use of tobacco products, alcohol, illicit drugs, over the counter medications, prescription drugs, rest and sleep patterns, extremes of exercise or physical exertion, and dental care.
The period of greatest sensitivity to the environment for the developing fetus is between 17 and 56 days after conception. Many structural anomalies have already occurred by the end of the eighth week and certainly by the end of the first trimester. In 1990, in Illinois, 20.7 percent of women received care only after the first trimester and 2.1 percent got no prenatal care at all, according to the Department=s Illinois Center for Health Statistics. Preconception counseling may affect some patients who otherwise would not seek care until after this critical period.
A chemical exposure history should be obtained, ideally prior to conception. Women should avoid significant exposure to chemical solvents and metal fumes and should carefully follow current guidelines for handling antineoplastic agents, including the use of vertical laminal flow hoods in their preparation.
A number of chemicals are of potential concern to human pregnancy. The effects of most of theses substances on human pregnancy are unknown, but several, such as heavy metals and organic solvents, have been implicated in a variety of reproductive disorders. It would seem prudent to educate women for whom pregnancy is a possibility regarding such hazards; help them identify their own exposure risks; and provide them with the facts available regarding the teratogenic potential of any drug, chemical, or environmental agent to which they are exposed.
It is important to ask the client about their environment contacts outside their daily work involvement.
This history should include inquiry about activities and products used by the client, as well as by other household members. This will include such environmental things as: Interview the client to assess the type of and place of employment. If the work environment would place the pregnancies in jeopardy.
It is important to ask the client about their environment contacts outside their daily work involvement.
This history should include inquiry about activities and products used by the client, as well as by other household members. This will include such environmental things as:
- Lead based paint
- Ceramic ware
- Soil/dust near lead industries
- Leaded gasoline
- Plumbing leachate
Inquiries regarding hobbies and related activities should include the following:
- Glazed pottery making
- Preparing lead shots
- Target shooting at firing ranges
- Fishing sinkers
- Stained glass making
- Lead solder (e.g electronics)
- Furniture refinishing
- Car and boat repair home remodeling
Questions should also be raised regarding a spouse taking home residue on clothing, e.g. in farm communities there may be exposure to pesticides and herbicides. Investigation regarding a safe water supply needs to be addressed. Learn whether the source of the client=s water supply is a public water supply (municipal) or private. If it is private, it is advised that the private well be sampled once during the past year for coliform and nitrate. The well should be free of coliform bacteria and contain no more than 10 mg./L. Of nitrates. Testing can be done through an approved private laboratory.
It is important to do a review of the client and her environment to evaluate social and behavioral factors that affect the client=s ability to function. This assessment includes a psycho-social historydetermination of current functioning, counseling relative to need, and community referrals for services.
Components of the assessment derived from the interview and updated medical record should include family composition and functioning (strengths and needs0, adjustment to pregnancy and parenting attitudes, perceptions of need for care, support systems of client and family (use of formal and informal resources), cultural issues regarding health care, pregnancy, family relationships, educational level, mental health status and history (family violence, depression, suicidal tendencies, key stressors and life events, maternal stress/anxiety extremes), pertinent medical history (e.g., substance abuse), and environmental needs and resources such as housing, financial resources, employment, clothing ,transportation, child care and community violence.
Ascertain whether the client is experiencing any emotional highs or lows about becoming a parent, or whether she is experiencing increased fatigue or stress, particularly if there are other youngsters at home or if she is employed outside her home. The client may have headaches due to stress or the headaches may be indicative of serious medical problems such as hypertension, proteinuria, or edema of the extremities. In such cases prompt contact with the medical provider is indicated.
The physical examination is performed for all women during the pre-conceptional visit or the first pregnancy visit. The elements of the physical examination include: general appearance and nutrition; blood pressure, pulse, height to weight profile, present weight; head and neck, heart and lungs, breasts, abdomen, pelvic area tenderness, extremities and back, neuromuscular; and pelvic evaluation - speculum and bimanual examination, clinic pelvimetry.
At each follow-up visit, the patient should be given an opportunity to ask questions about her pregnancy or comment on changes that she has noted. The physical exam should include general appearance, nutrition, blood pressure, weight (including pattern of weight gain), uterine size, heart rate of mother and fetus, and cervical check after 40 weeks. The cervical check should include dilatation effacement, fetal presentation, and station. The findings of this exam should be carefully documented and should be assessed during each visit. The patient should be asked about fetal movement at each visit. Urine should be checked to detect protein and glucose. Any change in the pregnancy risk assessment should be recorded after each evaluation and an appropriate management plan outlined. Continual risk assessment should be a standard part of the ante-partum care.
At 24 to 28 weeks gestation an interval history since the last visit should be obtained and should include questions on the general state of health, nutrition, fetal movement and unusual symptoms such as frequent contractions or vaginal bleeding. Continuing assessment is indicated of psycho-social risks, maternal stress or anxiety, and habits to determine significant changes and the need for support or other interventions. The physical examination should include weight as a measure of health for the woman and fetus; blood pressure as a continuing screen for hypertension; and auscultation of fetal heart rate, assessment of fetal activity, and fundal height for growth pattern.
A repeat hematocrit or hemoglobin is indicated during the second and third trimester to help monitor nutritional status and identify anemia. Since the one-hour glucose screen for diabetes is recommended for all women near 26 weeks, both laboratory tests can be done at this time. For Rh-negative women, a repeat Rh titer should be done at this visit and, if unsensitized, RhoGAM should be given. This is the beginning fo the third trimester and is 10 weeks after the previous risk assessment. At this time, diagnoses of problems such as toxemia, growth retardation, or abnormal fetal presentation may first be made. The timing also reflects the optimal screening time for pregnancy-induced diabetes and anemia.
Nutritional assessment during the initial prenatal visit should include the following subjective data:
- Pre-pregnancy weight (height to weight profile)
- Diet history with evaluation of barriers to adequate nutrition intake, (e.g., financial, cultural, food Fads, pica, and special dietary patterns (e.g.. vegetarian, lactose, intolerance, caffine, Aspertane