Assessment During Pregnancy

Assessment during pregnancy involves evaluating maternal and fetal health with the goal of a healthy pregnancy outcome. During the assessment, you’ll collect subjective data, or information your patient states, as well as objective data, or information you collect through observation.

Begin by collecting information about your patient’s reproductive and sexual health. Ask about their history of gynecological surgeries, especially those involving the cervix, since this could increase the risk of cervical insufficiency and early pregnancy loss; or the uterus, since this can increase the risk of obstetric complications like fetal malpresentation or uterine rupture.

Also, review your patient’s obstetric history using the GTPAL notation, to document Gravidity or how many times your patient has been pregnant; the number of Term pregnancies and Preterm births; if they’ve had either a spontaneous or elective Abortion; and the number of Living children.

Lastly, determine if they have a history of sexually transmitted infections, or STIs, which are risk factors for premature rupture of membranes, preterm labor, as well neonatal infections and birth defects.

Next, focus on their current pregnancy. Ask them about the first day of their last menstrual period and use this date to calculate the expected date of delivery, or EDD for short, using Naegele’s rule. Then, inquire about any new symptoms like pain, vaginal discharge, fatigue, or nausea and vomiting. Also be sure to ask them how they are feeling about their pregnancy, if the pregnancy was planned, and if they have any concerns that could adversely affect their pregnancy, such as intimate partner violence, lack of social support, or economic constraints.

Finally, review their medical history. Inquire about conditions that could complicate the pregnancy, like diabetes, hypertension, or asthma; current medications; known allergies; and immunizations. Also ask about their daily routine, including diet, physical activity, and sleep, as well as intake of caffeine and use of alcohol or tobacco products.

Okay, next perform a focused physical assessment. First, observe your patient’s general appearance, including posture, grooming, and affect. Then, assess their vital signs and measure their height and weight. Inspect their skin, making note of any previous cesarean section scars and the presence of pregnancy-related skin changes like chloasma, which is a dark pigmentation across the nose and face; or a dark vertical line on the abdomen called linea nigra.