11.2: First Prenatal Visit

Learning Objectives

By the end of this section, you will be able to:

• Obtain a comprehensive patient health history at the first prenatal visit
• Analyze the subjective and objective patient data obtained in the interval history since the patient’s last menstrual period
• Explain various methods of confirming a patient is pregnant
• Explain the physical examination performed at the first prenatal visit
• Explain the purpose of the laboratory tests obtained at the first prenatal visit
• Provide the patient education at the first prenatal visit

The 280 days of gestation (pregnancy) are divided into three periods, called trimesters. Each trimester is 14 weeks of gestation. The first trimester is from 0 to 13 weeks and 6 days of gestation, the second trimester is from 14 to 27 weeks and 6 days of gestation, and the third trimester is 28 weeks until delivery (American College of Obstetricians and Gynecologists [ACOG], 2017, Reaffirmed 2022).

Early and regular prenatal care is associated with a decreased incidence of complications of pregnancy (Osterman & Martin, 2018). The decrease in adverse outcomes for both the patient and newborn is most often attributed to the wealth of patient information provided at each prenatal visit. Two examples of this information include eating a healthy diet and avoiding intake of or exposure to harmful substances.

Patients are encouraged to schedule their first prenatal visit sometime between 8 and 12 weeks of gestation. This initial prenatal visit starts with obtaining the patient’s health history and current data related to the patient’s signs and symptoms of pregnancy. The pregnancy is confirmed and the patient’s due date is determined using the patient’s recall of the first day of their last menstrual period (LMP) and ultrasound (US) (if performed). A physical exam is completed, and initial prenatal laboratory specimens are obtained to be sent out for testing. The visit ends with patient teaching about multiple topics for keeping healthy during the pregnancy and scheduling the next prenatal visit.

Health History

At the first prenatal visit, a comprehensive health history is obtained. Demographic data are first asked of the patient. The next part of the health history includes the patient’s past medical and surgical history, list of current medications, family health and genetic history, lifestyle and health practices, current medications, history of drug use, and exposure to sexually transmitted infections (STIs). An obstetric history, nutritional assessment, depression screening, and intimate partner violence screen are also completed during the first prenatal visit. The goal of the health history is to obtain baseline data on the patient and the patient’s partner (or the biological father or sperm donor of the fetus) to identify risk factors that could affect the patient, fetus, and newborn.

Demographic Data

The age of a pregnant person can be a risk factor for complications, especially if the person is 19 years old or younger when conception occurred or will be 35 years old or older at the estimated date of delivery. Those at the lower and higher ends of the age continuum are at increased risk for preeclampsia, gestational diabetes, preterm delivery, prolonged labor, and delivery by cesarean section.

Where the patient lives provides cues for social determinants of health, such as potential problems with access to care (lack of reliable transportation to and from prenatal visits and diagnostic testing ordered during the pregnancy), exposure to environmental toxins, and neighborhood violence. Who the patient lives with impacts who shops for and cooks the meals as well as the money available for childbirth education and the needs of the newborn. Members of the patient’s household also indicate the support system available to the patient throughout the pregnancy and after the baby is born.

Sociocultural considerations, such as the patient’s race, ethnicity, religious practices, primary language, education, and occupation, often impact pregnancy. Race and ethnicity play a role in dietary intake and risk for certain genetic disorders. Religious practices may influence dietary intake and choice of prenatal care provider and place of delivery.

The patient’s primary language and highest level of education influence both their literacy and health literacy levels. The prenatal period is an optimal time for the nurse to screen for health literacy and for the health-care provider to increase the patient’s health literacy. Availability of medical interpreters and verbal and written education in the patient’s primary language is essential to promote awareness of actions to maintain a healthy pregnancy and early recognition of potential problems during the prenatal period.

Link to Learning

Medical and health-care interpreters provide a vital service interpreting and translating medical information between health-care personnel (nurses, dieticians, health-care providers) and a patient who speaks a different language. The medical information includes, but is not limited to, completing a health history and physical, obtaining informed consent, administering medications, and discharge instructions. There are various ways to train to become a medical or health-care interpreter and multiple choices to obtain certification. The National Board of Certification for Medical Interpreters is one example.

The occupation of both the patient and their partner can affect the pregnancy by exposing the new parents-to-be to stress and environmental pollutants. Stress can raise the patient’s blood pressure, decrease resistance to infection, interfere with sleep, and affect dietary intake, all of which influence fetal growth and development, thereby increasing the risk for low birth weight and preterm delivery. Stress can also increase the incidence of intimate partner violence during pregnancy. Exposure to environmental pollutants raises the risk for congenital malformations.

Medical and Surgical History

The patient’s medical and surgical history reveals past surgical procedures and current and past medical problems that may occur again or worsen during the pregnancy. Diabetes and hypertension are examples of current medical problems, and frequent urinary tract infections are an example of an intermittent medical problem increasing the risk for complications for the entire perinatal period. Surgeries and other procedures that may place the pregnancy at risk include previous uterine surgery, loop electrosurgical excision procedure (LEEP), and repair of a fractured pelvis.

Current Medications and Over-the-Counter Supplements

Obtaining a list of over-the-counter (OTC) medications; vitamins, minerals, and herbal supplements; and prescription drugs used by the patient since the first day of the patient’s last menstrual period provides the nurse or other health-care provider a baseline to screen for teratogens. The embryo and fetus are especially vulnerable to teratogens in the first 14 weeks of gestation, also known as the first trimester of pregnancy. The patient’s current medication and over-the-counter supplements list also provides the nurse with a foundation for patient education on medications, vitamins and minerals, and herbal supplements considered safe or contraindicated during pregnancy.

Patients with preexisting medical conditions are often taking drugs prescribed by other health-care providers. It is important for the patient to inform their other health-care providers they are planning to become or are currently pregnant. To ensure medication safety throughout the pregnancy, obstetric care providers often work hand-in-hand with other health-care providers, such as endocrinologists, when patients have thyroid disease or diabetes.

Lifestyle and Health Practices

It is important to discover if the patient is currently using or has a history of using tobacco products, alcohol, opioids, marijuana, or illegal substances, especially since the patient’s first day of their LMP. All of the listed substances are linked with adverse patient and fetal outcomes, increasing the risk for maternal and infant morbidity and mortality. Some over-the-counter and herbal supplements are also linked with adverse patient and fetal outcomes, and any intake needs to ascertained as well.

Discussing current exercise and activity level with the patient assists in developing an exercise plan during pregnancy. Exercise is encouraged because staying active during pregnancy is associated with fewer musculoskeletal complaints during pregnancy, decreased risk of preeclampsia and gestational diabetes mellitus, and shorter length of labor (Rodríguez-Blanque et al., 2019). If a patient was inactive prior to conception, exercise should be increased gradually.

Obtaining a 24-hour diet recall from the patient provides the data to evaluate the patient’s dietary habits and nutritional status. Inadequate or poor nutritional intake is associated with low birth weight, prematurity, and preeclampsia. Low fiber and inadequate water intake increase the risk of constipation during pregnancy.

Additionally, the patient should be asked if they currently use non-Western medical practices such as massage therapy, acupressure and acupuncture, Ayurveda, homeopathy, or home remedies. Some non-Western medical practices are safe during pregnancy, especially when provided by a trained and, when required, licensed person. The prenatal health-care provider should discuss the patient’s use of these practices throughout the pregnancy. (Table 11.1) provides a list of the information documented in the prenatal patient’s electronic health record (EHR) at the first prenatal visit.

Category	Information
Demographic information	Name Address Phone number Insurance Date of birth/age Marital status Language Race/ethnicity Religion Name of partner Pregnancy support person Education of pregnant person/partner Occupation of pregnant person/partner
Allergies	Drugs Other
Current medications
Menstrual history	Age at menarche Menstrual cycle interval Menstrual cycle duration First day of last menstrual period (LMP)
Estimated date of delivery (EDD)	By LMP By US
Pregnancy history	Gravida ___ T ___ P ___ A ___ L ___ Month/year of delivery Weeks of gestation at delivery Length of labor Type of delivery Sex of infant Infant weight at birth Anesthesia Complications during pregnancy anemia intrauterine fetal demise (IUFD) gestational diabetes hemorrhage hyperemesis cervical insufficiency postpartum (PP) depression pregnancy-induced hypertension (PIH) preterm labor (PTL) or birth group B streptococcus (GBS) positive multiple gestation infection Repeat information for each pregnancy
Gynecologic history	Past or current contraceptive use Abnormal Papanicolaou (Pap) smear STIs and vaginal infections gonorrhea chlamydia syphilis herpes human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS) human papillomavirus (HPV) trichomoniasis bacterial vaginosis Fibroids Gynecologic surgery Infertility Uterine and cervical anomalies Abnormal uterine bleeding
Infection history	Toxoplasmosis Cytomegalovirus (CMV) Rubella status Varicella Hepatitis A, B, and C
Medical history	Genetic disorder Cancer Hypertension (HTN) Cardiac disease Rheumatic fever Asthma Chronic obstructive pulmonary disease (COPD) Other pulmonary disease Gastrointestinal (GI) conditions Renal and urinary tract conditions Gynecologic conditions Varicosities Endocrine disorders Anemia Blood dyscrasia Substance use (drugs, smoking, alcohol) Infectious disease Accidents/injuries Blood transfusion Other
Hospitalizations	Date Reason Repeat for each occasion
Surgeries	Name Date Repeat for each surgery
Immunizations	Tetanus, diphtheria, and pertussis (Tdap) Influenza COVID Varicella Measles, mumps, and rubella (MMR) Hepatitis A (Hep A) Hepatitis (Hep B)
Interval history since LMP	Vaginal bleeding Abdominal or epigastric pain Headache Dizziness or syncope Visual change Nausea and vomiting Urinary complaints Fever Infections Trauma or accident Other
Exposure to teratogens	STIs TORCH Varicella Hepatitis Work chemicals Radiation Other
Substance use (type and amount per day)	Nonprescribed drugs Herbal preparations Prescribed drugs Alcohol Tobacco Marijuana Other drugs
Genetic history, patient	Sickle cell anemia Thalassemia Cystic fibrosis Tay-Sachs disease Hemophilia Muscular dystrophy Huntington chorea Neural tube defects Trisomy or other chromosomal disorder Developmental delay Neurologic deficit Autism spectrum disorder Fragile X Other chromosomal or genetic disorder Recurrent pregnancy loss Metabolic disorder Other
Genetic history of other biological parent of baby	Sickle cell anemia Thalassemia Cystic fibrosis Tay-Sachs disease Hemophilia Muscular dystrophy Huntington chorea Neural tube defects Trisomy or other chromosomal disorder Developmental delay Neurologic deficit Autism spectrum disorder Fragile X Other chromosomal or genetic disorder Recurrent pregnancy loss Metabolic disorder Other
Nutrition assessment	Normal food and drink for breakfast Normal food and drink for lunch Normal food and drink for supper Normal food and drink for snacks Eating disorder Malnourished Special diet Vitamin and mineral supplements Herbal supplements Caffeine intake
Activity assessment	Job outside home Work at home Exercise Leisure activities
Psychosocial assessment	Housing Financial restrictions Transportation restrictions Access to phone Access to utilities Support person(s) Adaptation to pregnancy Safety at home Presence of abuse History of depression
Assessment of preexisting conditions placing the pregnancy at risk	Age < 19 and > 35 < 8th-grade education Cardiac disease COPD Current endocrine disease Epilepsy Two or more abortions Five or more births at > 20 weeks Previous preterm births Previous intrauterine growth restriction (IUGR) infant Previous large for gestational age (LGA) infant Rh sensitization Previous ABO incompatibility Previous antepartum hemorrhage Previous preeclampsia Second pregnancy within 12 months of previous delivery Smoking more than one-half pack per day Diabetes mellitus Hypertension Chronic renal disease Hemoglobinopathy Congenital anomaly Genetic anomaly Cervical insufficiency Fetal or neonatal death Previous neurologically damaged infant Presence of social determinant of health

Table 11.1 Information Included in the Prenatal Health History

Obstetric and Gynecologic History

During the obstetric history-taking process, the patient’s estimated date of delivery (EDD) will be determined. The EDD is the date the pregnant patient is expected to give birth, plus or minus 2 weeks. Information about any previous pregnancy is obtained to establish the patient’s gravidity and parity, both of which will be defined and discussed later in this section. A gynecologic history is important to discover additional risk factors affecting the pregnancy.

Estimated Date of Delivery (EDD)

When the pregnant patient is sure of the first day of their last menstrual period, the EDD is determined using Naegele’s Rule. Naegele’s Rule is a three-step calculation based on a 28-day menstrual cycle used to determine a pregnant patient’s due date. Using Naegele’s Rule, the nurse first subtracts 3 months from the first day of the last menstrual period (LMP). In the second step, the nurse adds 7 days to the LMP. Any needed adjustment to the year is the final step of Naegele’s rule (Table 11.2). The “plus or minus 2 weeks” of the calculated EDD takes into consideration the normal variations in a menstruating person’s cycle.

Calculation	Example
Date of LMP	April 6, 2022
Subtract 3 months	January 6, 2022
Add 7 days	January 13, 2022
Adjust the year [if needed]	January 13, 2023

Table 11.2 Calculating the EDD Using Naegele’s Rule

Gravidity and Parity

Gravidity and parity (G/P) indicate the patient’s reproductive history in numerical form. The total number of times the patient has been pregnant (including the current pregnancy) regardless of the outcome or number of fetuses is gravidity, while parity is the number of pregnancies where the patient has reached 20 weeks of gestation or more, regardless of whether the pregnancy ended in a live birth or fetal demise or the number of fetuses (ACOG, 2014). Thus, for a patient who is pregnant for the third time and the outcome of the two previous pregnancies was a live birth at 37 weeks and a fetal demise at 28 weeks, the nurse would document G3/P2. Abortion is the medical term for a pregnancy ending at 20 weeks of gestation or less, whether spontaneous or induced.

Gravidity and parity can be expanded upon in several ways based on the health-care provider’s preference. The most common method of detailing gravidity and parity is using the G/TPAL (gravida, term, preterm, abortion, living) method (ACOG, 2014).

• G: Gravida (or gravidity) is the number of pregnancies, including the current pregnancy.
• T: Term is the number of births at 37 weeks of gestation and later.
• P: Preterm is the number of births at >20 weeks of gestation and before 37 weeks.
• A: Abortion is the number of pregnancies ending before 20 weeks of gestation.
• L: Living is the number of children the pregnant patient has given birth to who lived past 28 days from the date of birth.

To determine a patient's gravidity and parity using G/TPAL, follow this process:

1. Determine how many times the patient has been pregnant. This is the gravida, or G.
2. Determine the number of times the patient has given birth at 37 weeks of gestation or later. This is the number of term, or T, births.
3. Determine the number of times the patient has given birth after 20 weeks of gestation but before 37 weeks. This is the number of preterm, or P, births.
4. Determine the number of times the patient has given birth at less than 20 weeks of gestation. This is the number of abortions, or A.
5. Determine the total number of living children the patient has given birth to. This is the number of living, or L.

For example, consider a pregnant patient whose reproductive history reveals she has given birth twice. The first child was born a week early, and the second child was born 4 weeks early. She also miscarried twins during the fourth month of pregnancy. Using the G/TPAL method:

1. G = 4 (she is currently pregnant)
2. T = 1 (1 week early is 39 weeks)
3. P = 1 (4 weeks early is 36 weeks)
4. A = 1 (4 months is 16 weeks, and a multiple gestation pregnancy is considered one birth)
5. L = 2

This patient's G/TPAL is G4 P1112.

Gynecologic History

The gynecologic history provides information that may place the pregnancy at risk and includes whether the pregnant person has ever been diagnosed with any reproductive cancer, breast disorder, menstrual disorder, and sexually transmitted infections. Any reproductive surgeries or diagnostic tests are also part of the gynecologic history. Multiple terminations of pregnancy or dilatation and curettage (D&C) and cervical biopsies and procedures weaken the cervix and place the pregnant person at risk for cervical insufficiency and preterm delivery. Multiple terminations of pregnancy can also produce cervical scarring, leading to problems with cervical dilation during labor. Known uterine anomalies can also increase the risk of preterm delivery. Previous uterine surgeries increase the risk of abnormal placement of the placenta and uterine rupture during labor, and a cesarean birth may be recommended based on the location of the placenta and type of uterine scar. Breast surgery can interfere with breast-feeding.

Genetic History

The genetic history includes information on the patient who is pregnant, the biological father or sperm donor of the fetus, and their respective families. Any known genetic condition of the parents and their families that can be inherited by the fetus is documented. The most common genetic conditions are the following:

• cystic fibrosis,
• trisomy 21,
• Tay-Sachs disease,
• hemophilia,
• sickle cell disease or trait,
• congenital mental impairment, and
• congenital anomalies.

Other factors that increase the risk for inherited disorders are also included in the genetic history, such as maternal and paternal age and consanguinity (shared ancestry, such as when the parents are first cousins).

Initial Screening for Factors Placing the Pregnancy at Risk

The first prenatal visit begins the screening process for factors placing the pregnancy at risk for perinatal complications. The obstetric and gynecologic history, along with the medical and surgical histories, is reviewed to determine preexisting risk factors affecting the maternal and fetal outcome. Also discussed throughout this section are demographic, sociocultural, and genetic factors linked to an increased risk for maternal and fetal complications. The most common of these preexisting conditions include the following:

• maternal age <19 at conception or ≥35 at the EDD
• obesity
• nutritional deficiencies
• substance use
• hypertension
• diabetes
• HIV
• STIs
• hepatitis B and C
• herpes simplex
• cardiac disease
• renal disease
• epilepsy
• psychiatric disorders
• cervical procedures or surgeries
• uterine anomalies
• uterine surgery
• obstetric complication in a previous pregnancy

Table 11.3 lists social determinants of health linked with complications of pregnancy. Many of the risk factors are present at conception, and other risk factors are specific to pregnancy.

Social Determinant of Health	Complication of Pregnancy
Economic stability: low income	Spontaneous abortion Preterm delivery Preeclampsia Low birth weight Perinatal mortality
Physical environment: poor housing and neighborhood	Exposure to teratogens Low birth weight Preterm delivery Behavioral health disorders
Education: less than high school	Preterm birth
Nutrition: poor diet	Spontaneous abortion Preterm delivery Preeclampsia Perinatal hemorrhage Low birth weight Perinatal mortality
Support system: inadequate	Low birth weight Preterm delivery Behavioral health disorders
Access to care	Spontaneous abortion Preterm delivery Preeclampsia Perinatal hemorrhage Low birth weight Perinatal mortality

Table 11.3 Social Determinants of Health Linked to Complications of Pregnancy

Early and consistent prenatal care helps to both prevent and limit complications of known risk factors. Prenatal care provides opportunities to recognize early signs and symptoms to prevent the development of severe and life-threatening complications. Each prenatal visit aids in reaching the Healthy People 2030 goal to decrease maternal and newborn morbidity and mortality (U.S. Department of Health and Human Services [DHHS], 2021).

Interval History since Last Menstrual Period

After completion of the health history and risk assessment, the focus of the first prenatal visit turns to the reason the patient scheduled the initial prenatal visit: confirmation of the pregnancy. Typically, the patient has missed one or two menstrual periods, and a home pregnancy test result was positive. To confirm the pregnancy, the nurse will obtain baseline subjective and objective data from the patient.

Baseline Subjective Data

The nurse asks the patient a series of questions (known as the interval history). The questions are specific to the patient’s current gestation and inquire about the presence of nausea, vomiting, dizziness, breast tenderness, vaginal discharge and spotting, and lower backache and uterine cramping. Nausea and vomiting, fatigue, and breast tenderness are expected symptoms in early pregnancy. Dizziness, vaginal discharge and spotting, and lower backache and uterine cramping are not expected and require further investigation.

Baseline Objective Data

The baseline objective data for the first prenatal visit include the patient’s height and weight, blood pressure and pulse, and urine dipstick results. The height and weight are entered into the EHR and are used to calculate the patient’s body mass index (BMI). When the patient is underweight, overweight, or obese, expectations for weight gain during pregnancy are different than for the patient who has a normal BMI.

The patient’s blood pressure (BP) and pulse are taken to determine normal values. The blood pressure of a pregnant person is expected to be below 120/80 mm Hg and the pulse 60 to 120 beats per minute. A slightly elevated BP may be attributed to anxiety or excitement about the pregnancy or may indicate a preexisting hypertensive disorder. Tachycardia at the first prenatal visit may indicate anxiety or a preexisting cardiac condition. It is important for the nurse to ask the patient if they know what their BP has been in the past when the BP obtained at the first or any prenatal visit is elevated.

A urine dipstick test is performed to check for protein, blood, glucose, ketones, bacteria, and nitrites in the urine. At the first prenatal visit, the presence of protein in the urine can be interpreted as contamination from vaginal discharge or an indication of preexisting renal disease. The presence of blood in the urine can be caused by vaginal bleeding or by a urinary tract infection. Glucose in the urine can be a sign of preexisting diabetes. Ketonuria occurs as a result of excessive vomiting. Bacteria and nitrites indicate the presence of a urinary tract infection. The nurse should review the pregnant person’s health history and answers to the intake questions when there are any unexpected results in the urine dipstick and inform the health-care provider. The urine dipstick test is also performed to detect asymptomatic urinary tract infections, which, if not treated, can result in acute pyelonephritis (Smaill & Vazquez, 2019).

Confirmation of Pregnancy

After the patient’s history of present illness is completed, either a urine pregnancy test will be performed to confirm the probability of pregnancy, or the patient will have a pelvic ultrasound (US) to confirm a viable intrauterine pregnancy. The method of confirmation is based on the capabilities of the office or clinic where the initial prenatal visit takes place. Some private practices and many community or county clinics do not have an ultrasonographer and will refer the patient to a facility with ultrasound capability.

Pregnancy Tests

Pregnancy tests can be performed using the patient’s urine or blood. The advantage to using urine is that the test can be performed at the same place as the initial prenatal visit. Both urine and serum pregnancy tests detect the human chorionic gonadotropin (hCG) hormone. The urine pregnancy test detects only the presence or absence of hCG, while blood serum pregnancy tests can detect the presence or absence of hCG (qualitative) or, when desired, the amount of hCG (quantitative). Quantitative serum hCG levels are most often ordered when there is no gestational sac or cardiac activity detected by the pelvic US.

Ultrasound

The pelvic US at the first prenatal visit (when performed) provides important objective data. First, the US confirms the presence of fetal cardiac activity. Second, the US confirms an intrauterine pregnancy and rules out an ectopic pregnancy. Third, the US can confirm the EDD by measuring the dimensions of the gestational sac or fetus during the first trimester of pregnancy. Finally, the pelvic US also provides data on the number of fetuses present in the uterus.

Physical Examination

The physical examination is the next step of the first prenatal visit and includes the head-to-toe and gynecologic pelvic exams. The data obtained during the physical exam provide the baseline assessment of the patient’s current physical condition. The baseline data are compared with future data obtained throughout the pregnancy for changes or trends, screening for or indicating the development of complications that place the pregnancy at risk.

Informing the patient about what to expect during the head-to-toe and pelvic exams can decrease any patient anxiety. Following the attributes of trauma-informed care, recognition, knowledge, concern, and respect are especially important if this will be the patient’s first pelvic exam or if there is any history of sexual abuse (Guest, 2021). The patient will be asked to remove all clothing, including undergarments, and put on a paper or cloth gown before the physical examination begins. The presence of a support person during the physical exam can increase the patient’s comfort level and should be offered to the patient or be a standard of practice.

Head-to-Toe Exam

The head-to-toe exam is performed in a methodical manner with the patient first sitting on the exam table. The health-care provider starts with observation of the patient’s posture and cleanliness and other parts of the general survey. Speech and hearing are assessed when asking the patient questions to clarify specific points in the health history. The depth of the head-to-toe exam is based on the current health of the patient and includes, but is not limited to, the head and neck, back, extremities, anterior thorax and breasts, and abdomen.

Head and Neck

Examination of the head and neck begins with assessment of the skin, hair distribution, and facial feature symmetry. Clarification of the patient’s ability to see, hear, and smell occurs by asking questions, such as whether the patient wears glasses or contact lenses. Inspection of the patient’s mouth for lesions, gum disease, and dental caries is important in determining any possible influences on nutritional intake. Gum disease is associated with an increased risk of preterm delivery (Erchick et al., 2020).

Range of motion of the neck is assessed by having the patient turn their head from side to side, then look up at the ceiling and down to the floor. Assessment of the neck includes palpation of the thyroid. Enlargement of the thyroid or the presence of any mass or nodule requires more data, such as thyroid function blood tests, and referral to an endocrinologist.

Back

When examining the patient’s back, the skin is assessed for dryness, scars, and lesions, such as acne or nevi. Any abnormalities observed on the skin require further investigation. Inspection of the patient’s spinal curvature and palpation of the vertebrae for tenderness are also performed. Clarification of any history of scoliosis and back injury or surgery is important to discover possible contraindications to epidural or spinal anesthesia during the birth process that require further investigation. Checking for the presence of costovertebral angle tenderness (CVAT) is performed to rule out possible pyelonephritis or other renal conditions.

Auscultation of the patient’s breath sounds through the posterior thorax is performed next. Breath sounds are expected to be clear. Adventitious breath sounds, as with any abnormal assessment data, need to be investigated to determine the cause.

Extremities

The extremities are assessed for symmetry of range of motion, strength, circulation, and any presence of edema. A patient with limited use of their arms and hands, such as from brachial plexus injury or amputation, may require assistive devices to care for their newborn. Normal range of motion of the legs is important during the second stage of labor when bearing down to deliver the baby vaginally. This may limit birthing options for patients with impairment in their lower limbs, such as cerebral palsy or spinal cord injury. The nurse should also ask the patient if they have any difficulty walking in order to determine the current or future need for assistive devices during pregnancy.

Circulation is assessed by palpating the radial and pedal pulses bilaterally and examining the lower extremities for varicosities. The absence of edema in the lower extremities is expected at the first prenatal visit. The presence of edema at the first prenatal visit may indicate preexisting renal or cardiac disease and requires further investigation.

Additionally, the patient’s patellar deep tendon reflexes (DTRs) and the presence or absence of clonus are assessed bilaterally. Normal reflexes and the absence of clonus are expected in the patient who is pregnant. Hyperreflexia and the presence of clonus at less than 20 weeks of gestation may be normal for some patients. At 20 weeks of gestation or more, hyperreflexia and the presence of clonus (if not present at the first prenatal visit) are one sign of pre-eclampsia, a medical condition limited to pregnancy, as discussed in Chapter 12 Pregnancy at Risk.

Anterior Thorax and Breasts

The examination of the anterior thorax includes assessment of the skin, shape of the rib cage, breasts, heart, and lungs. The skin is assessed for color and the presence of acne, nevi, and scars. The shape of the rib cage is assessed, and any abnormal curvature is investigated. The patient is asked to lie down on their back on the examination table for the remainder of the head-to-toe exam.

The breasts and nipples are inspected for symmetry in size, shape, and location. The nipples are also assessed for inversion (Figure 11.2). Inverted nipples are linked with difficulty in breast-feeding. Referral to a lactation consultant can assist the patient to overcome any obstacles to successful breast-feeding caused by inverted nipples. It is important for the health-care provider to discuss the presence of breast tenderness before and during palpation of the breasts.

Figure 11.2 Inversion of Nipples Comparison of the normal everted nipple to a flat and inverted nipple. (CC BY 4.0; Rice University & OpenStax)

The heart sounds are auscultated at the aortic and mitral valves, using both the bell and diaphragm of the stethoscope. If the heart sounds indicate possible aortic valve stenosis or mitral valve prolapse at the first prenatal visit, the extra blood volume during pregnancy can exacerbate these conditions, resulting in heart failure. Early recognition of abnormal heart sounds requires the nurse to review the patient’s cardiac history and have the patient evaluated by their cardiologist or arrange a referral to a cardiologist if needed. Systolic flow murmurs are common after 24 weeks of gestation due to the normal increase in blood volume during pregnancy.

Breath sounds are auscultated through the anterior chest wall and are expected to be clear. Auscultation of the side walls of the chest may be required when the patient has large breasts interfering with anterior chest auscultation. Adventitious breath sounds require further investigation.

Abdomen

The abdominal examination starts with inspection of the skin for color, hair distribution, nevi, and scars. The contour of the abdomen is noted, and any protuberance is assessed to rule out an umbilical hernia or other abnormality. As the pregnancy progresses, the enlarged uterus will become visible as well as the linea nigra and striae gravidarum. Auscultation of the bowel sounds in all four quadrants is performed next.

Palpation of the abdomen is performed to determine the lower liver margin and the absence of any distention or abdominal masses. If the patient is at 12 or more weeks of gestation, the fundal height is noted. The fundal height is the measurement from the symphysis pubis to where the fundus (or top) of the uterus is palpated. The uterine fundus is expected to be at or right below the symphysis at 12 weeks of gestation, halfway between the symphysis and the umbilicus at 16 weeks, and at or just below the umbilicus at 20 weeks of gestation. If the patient is at 10 or more weeks of gestation at the first prenatal visit, fetal heart tones are auscultated via Doppler monitoring, and the fetal heart rate is counted in beats per minute.

Pelvic Exam

A pelvic examination, if performed, has three steps: inspection and palpation of the external genitalia, the intravaginal speculum examination, and the bimanual examination. The pelvic exam is performed with the patient in the lithotomy position. The health-care provider performing the exam wears a pair of nonsterile latex-free exam gloves. The pelvic exam may be deferred, especially if the patient is very young or has a history of sexual trauma.

External Genitalia

The patient’s external genitalia and perineum are first inspected for normal development, placement of the urinary meatus, and hair distribution. The presence of any rashes, lesions, or discharge is discussed with the patient to determine if the symptom is new or ongoing. Any visible hemorrhoids are discussed with the patient. Normal findings and abnormalities are documented, and treatment is implemented per protocol as needed.

Cultural Context

Genital Mutilation of Persons Assigned Female at Birth

Female genital mutilation (FGM) is defined as all procedures that involve partial or complete removal of the external genitalia in those assigned female at birth (World Health Organization [WHO], 2023). There is no medical indication for FGM, and reasons for its continuance are sociocultural in 30 African nations, the Middle East, and Asia. In the antepartum period, the role of the nurse focuses on education of the pregnant person and partner/coach. The education includes a discussion on the medical complications linked to FGM and the myths and misconceptions surrounding resuturing after vaginal delivery. The conversation should be private and nonjudgmental. In the intrapartum period, the nurse may care for a patient who is scheduled for a cesarean birth due to the FGM or a patient who has chosen to deliver vaginally, and more time will be needed to repair the labia, vagina, and perineum. The nurse caring for the patient with FGM in the postpartum period will provide education on the importance of keeping the perineum clean and pain relief measures (Royal College of Obstetricians and Gynecologists, 2015).

Speculum Exam

Once examination of the external genitalia is completed, the patient is informed that the next step is inspection of the vagina and cervix using a vaginal speculum. The speculum is lubricated with warm water prior to insertion. It is important for the patient to understand they will feel discomfort when the speculum is inserted. Informing the patient that the nurse or other health-care provider is about to touch the opening of the vagina and insert the speculum helps to decrease the level of discomfort. Once the speculum is inserted, the nurse can also inform the patient that they are going to open the speculum and that the patient will feel additional pressure at both the opening of and within the vagina.

Clinical Safety and Procedures (QSEN)

Nursing Actions When Assisting with a Speculum Exam

When assisting the health-care provider during a speculum exam, the nurse will perform the following actions:

1. Have the necessary supplies ready. These include supplies needed to obtain any vaginal or cervical cultures and a Pap smear, if indicated.
2. Ask the patient to remove clothing below the waist and provide the patient with a covering.
3. Wear nonsterile exam gloves during the speculum exam.
4. Assist the provider by handing the supplies to obtain any cultures or a Pap smear.
5. Label the specimens obtained and complete any laboratory forms.
6. Follow facility procedures for sending specimens to the laboratory for processing.

Nursing Actions When Performing a Speculum Exam

1. The nurse will explain to the patient why the speculum exam will be performed.
2. The nurse should discover if this is the patient’s first speculum exam.
3. For the first speculum exam, the nurse should show the patient the speculum and discuss how the speculum is inserted and opened.
4. Before the speculum is inserted, the nurse will ask the patient to relax by taking slow deep breaths or closing their eyes and visualizing themselves at the beach.
5. While the speculum is in the vagina, the nurse will discuss any testing that is performed.
6. The nurse will inform the patient that the speculum is being removed.
7. The nurse will assist the patient into a sitting position and ask the patient if they have any questions.

During the speculum exam, the vaginal mucosa is observed for color, moisture, edema, and lesions. The vaginal mucosa is expected to be purple with some edema and an increase in mucus production caused by the increase in blood supply to the pelvic organs during pregnancy. Excessive vaginal discharge that is not clear and is malodorous needs to be investigated for the presence of a vaginal infection and treated based on the cause of the infection. White patches on the vaginal walls are associated with candidiasis, overgrowths of vaginal tissue may indicate human papillomavirus (HPV) lesions, and small blisters may be herpes simplex virus (HSV). Treatment regimens safe during pregnancy will be prescribed.

Insertion of the speculum into the vagina also allows for visualization of the cervix. Like the vaginal mucosa, the cervix is observed for color, moisture, size, discharge, erosion, and lesions. Pregnancy increases the blood supply to the cervix, causing the cervix to appear blue or purple (Chadwick sign). If a patient has never been pregnant before, the cervix and cervical os are smaller than in a person who has given birth or had an abortion (King et al., 2019) (Figure 11.3).

Figure 11.3 Appearance of Cervical Os (a) The cervical os of a person who has never been pregnant or is pregnant for the first time is round and small. (b) The cervical os of a person who has had one or more previous pregnancies will appear to be a slit. (CC BY 4.0; Rice University & OpenStax)

Clear mucus is expected at the cervical os, and the cervix should be free of lesions. At this time a Pap smear is performed, if indicated based on the patient’s gynecologic history, and a chlamydia and gonorrhea culture is obtained. Testing for chlamydia and gonorrhea is indicated for all patients at the first prenatal visit. Upon completion of all testing and visualization, the speculum is withdrawn. When the speculum examination is performed, documentation will include both normal and abnormal findings obtained during the exam.

Bimanual Exam

The bimanual exam is performed by the nurse or other health-care provider by inserting two fingers of one hand into the vagina and placing the other hand just above the patient’s symphysis pubis. The fingers within the vagina palpate the vaginal walls to assess for normal contour and tone, any palpable growths such as HPV lesions, and the presence of a cystocele or rectocele.

After palpating the vagina, the health-care provider palpates the cervical os, which is expected to be smooth, soft (Goodell sign), and closed. If the cervical os is open, a finger is gently inserted to determine if only the external os or both the internal and external cervical os are open. The cervical length is also assessed and expected to be 4 to 5 cm. A cervix that is open and is shortened at less than 20 weeks of gestation is associated with an increased risk of pregnancy loss (King et al., 2019).

While applying gentle suprapubic pressure with the external hand, the provider palpates the lower uterine segment for smoothness. HPV lesions and fibroids can be palpated if present. The size of the uterus can be estimated using the distance between the external hand over the anterior uterus and the internal fingers touching the posterior uterus. When an ultrasound is not available, determining the size of the uterus is important to confirm the patient’s current gestation and EDD. Using the anterior to posterior uterine diameter measurement fruit-equivalent method, an 8-week uterus diameter is the size of a lemon, a 12-week uterus diameter is the size of a large orange, a 16-week uterus diameter is the size of a grapefruit, and a 20-week uterus diameter is the size of a cantaloupe.

The bimanual exam is followed by clinical measurements of the pelvis. The assessment of the general shape and size of the patient’s pelvis is clinical pelvimetry (King et al., 2019). The pelvic inlet, midplane, and outlet are assessed using the diagonal conjugate, prominence of the ischial spines, curvature of the sacrum and coccyx, width of the pubic arch, and width of the intertuberous diameter (Figure 11.4). Clinical pelvimetry at the first prenatal visit allows for identification of pelvic structure anomalies that may interfere with the normal progress of labor.

Figure 11.4 Clinical Pelvimetry (a) The examiner assesses the diagonal conjugate by inserting two fingers into the vagina and measuring the length from the pubic arch to the sacrum. (b) Clinical pelvimetry will provide the health-care practitioner with information about the prominence of the ischial spines. (c) The examiner measures the angle of the pubic arch, which is expected to be greater than 90 degrees. (d) The examiner can measure the intertuberous diameter by placing their fist on the buttocks of the patient. Combined, the measurements of clinical pelvimetry are used to determine an increased risk for cesarean delivery. (CC BY 4.0; Rice University & OpenStax)

Initial Prenatal Laboratory Tests

Multiple laboratory test specimens are collected during the first prenatal visit. These tests provide information on the presence or absence of specific STIs, immunity to or history of infections, and current status of a preexisting medical condition. The tests also determine risk for or presence of genetic abnormalities in the fetus.

Blood Type, Rh, and Antibody Screen

The patient’s blood type, Rh factor, and antibody screen are obtained to determine if there might be a problem in obtaining needed blood products if the patient hemorrhages during the antepartum, intrapartum, or postpartum period. If the patient is Rh negative, antepartum Rho(D) immune globulin will be administered if pregnancy-related bleeding occurs at any time before labor. Rho(D) immune globulin prevents the development of isoimmunization during pregnancy. A negative antibody screen demonstrates the patient has not developed isoimmunization from a previous pregnancy or blood transfusion. A positive antibody screen at the first prenatal visit requires further investigation for possible interactions between the pregnant person and the fetus, compromising the outcome of the pregnancy.

Complete Blood Count (CBC)

The complete blood count (CBC) provides the patient’s current number of white blood cells (WBCs) and red blood cells (RBCs), hemoglobin and hematocrit (H&H), iron indices, and platelet count. The WBC count reflects the absence or presence of infection in the patient. The RBC count, H&H, and iron indices determine the absence or presence of anemia in the patient. If anemia is present, the values of the RBC, H&H, and iron indices can determine if the anemia is due to an inadequate dietary intake or a medical condition. The platelet count reflects the ability of the patient’s blood to clot. A platelet count less than normal places the patient at risk for bleeding and can be diagnostic of a clotting disorder.

Rubella Titer

The patient’s current rubella titer is obtained to determine immunity to the disease. The rubella virus can pass through the placenta and infect the fetus at any gestation of pregnancy and cause multiple congenital anomalies, such as blindness, deafness, cognitive impairment, and heart disease. If the patient’s rubella titer does not indicate immunity to the disease, the patient is instructed to report exposure to any person with a rash or who has been diagnosed with rubella. The rubella vaccine will be prescribed to the patient in the hospital after delivery and administered before discharge from the postpartum unit. The vaccine is not administered during pregnancy because it is a live vaccine and can transmit the virus to the fetus.

Hepatitis B and C

A hepatitis B and C panel is obtained to determine if the patient currently has an active hepatitis infection or has had one in the past. The panel will also indicate if the patient has chronic hepatitis. If the patient is currently infected with acute or chronic hepatitis, the virus can pass through the placenta and infect the fetus. Hepatitis during pregnancy is associated with a high risk of maternal and newborn morbidity and mortality.

Sexually Transmitted Infections

A venereal disease research laboratory (VDRL) test or rapid plasma reagin (RPR) test is performed to screen the patient for syphilis. If the VDRL or RPR test is positive, the treponemal assay test is done using the patient’s blood to determine if there is a current infection. Treponema pallidum (the bacterium causing syphilis) crosses the placenta and infects the fetus. Even with treatment, the fetus exposed to syphilis may contract syphilis and may die in utero, especially if the patient goes untreated during the first 16 weeks of gestation. Fetuses who are born alive with syphilis have similar congenital anomalies as infants who were exposed to rubella in utero. Treatment of the patient, their current partner, previous partners, and the newborn is carried out based on current Centers for Disease Control and Prevention (CDC) guidelines.

Link to Learning

The CDC’s STI Treatment Guidelines website provides information on both testing and treatment for STIs for both pregnant and nonpregnant persons. The guidelines also include education on prevention and signs and symptoms. Nurses employed in Family Planning and STI Clinics will use these guidelines to develop protocols and provide patient education.

An HIV antibody or antigen blood test is performed. If the test is positive, the patient will be started on zidovudine, an antiretroviral drug known not to cause congenital anomalies in the fetus. When the parent is treated during pregnancy and the infant is treated starting immediately after birth, the chance of the infant getting HIV is less than 1 percent (U.S. Department of Health and Human Services, n.d.). Testing and treatment of the patient, current partner, and previous partners is carried out based on current CDC guidelines.

Testing for gonorrhea and chlamydia infections is routinely done during the first prenatal visit. The test is most often performed using a cervical specimen obtained during the pelvic exam. As with HIV and syphilis, testing and treatment of the patient, current partner, and previous partners are recommended based on current CDC guidelines. The bacteria causing gonorrhea and chlamydia do not cross the placenta. However, risk to the fetus occurs once the membranes have ruptured. Prophylactic antibiotics are administered to the newborn’s eyes to prevent infection.

Sexually transmitted infection testing is repeated for testing of cure when needed and during the final weeks of pregnancy. This second testing is most often performed around 36 weeks’ gestation and will identify anyone who was recently exposed at the initial time of testing or a possible new exposure.

Urinalysis and Urine Drug Screen

In addition to the urine dipstick test performed in the office or clinic, the patient’s urine specimen is sent to the laboratory for a urinalysis, urine culture and sensitivity (C&S), and (depending on facility protocol) urine drug screen (UDS). The urinalysis and C&S are ordered because urinary frequency is one of the signs of both pregnancy and a urinary tract infection (UTI). A pregnant patient may overlook the symptoms of a UTI or have asymptomatic bacteriuria and go untreated. The UDS is most often obtained as a screening tool for current use of substances. The most common drug categories included in the UDS are amphetamines, cocaine, marijuana, opiates, phencyclidine, benzodiazepines, barbiturates, methaqualone, and methadone (Substance Abuse and Mental Health Services Administration, 2023).

If the UDS is positive, the nurse and health-care provider will first review the EHR and list of current medications to determine any links to the UDS results. It is important for the nurse or health-care provider to discuss the effects of the substance(s) on the patient, fetal growth and development, and pregnancy outcome, such as preterm delivery. The patient will also be informed about and consent to a random UDS to be repeated at one or more future prenatal visits and when admitted to the hospital for delivery (Ecker et al., 2019). Throughout the dialog with the patient, a nonjudgmental approach is indicated. A discussion of programs offering supportive services should be provided first before any discussion on mandatory reporting to social services is introduced.

Genetic Screening

Initial prenatal lab tests also screen the patient for sickle cell trait and disease. Cystic fibrosis gene mutation carrier screening is also offered during the first trimester. If either or both of the patient’s screens are positive, the biological father of the fetus should also be tested, if possible. If either or both of the biological father’s screens are also positive, chorionic villi sampling (if the patient is at 10 to 12 weeks of gestation) and amniocentesis are discussed with the patient.

Cell-free DNA testing uses a sample of the patient’s blood to screen for the presence of specific chromosome abnormalities of the fetus. The earliest the sample for the cell-free DNA screen can be drawn is at 10 weeks of gestation. The chromosome abnormalities screened for are trisomy 21, 18, and 13 and abnormalities in the sex chromosomes. Cell-free DNA is not as accurate as an amniocentesis or chorionic villi sampling.

Additional Laboratory Tests

Additional laboratory tests may be performed at the first prenatal visit (Table 11.4). These tests include, but are not limited to, the Pap smear, gestational glucose screen, complete metabolic panel (CMP), thyroid function panel, and herpes simplex titers. If the patient is 21 years or older, a Pap smear is obtained during the pelvic exam to screen for cervical precancerous and cancer cells. This test is done if indicated based on the patient’s age and the amount of time since any previous cytology study was performed, as well as the patient’s risk status depending on previous Pap smear results (ACOG, 2021a). The patient’s blood is drawn for a CMP if they have a history of medical conditions, such as renal or liver disease, hypertension, or diabetes. Herpes simplex 1 and 2 antibodies are sometimes included with the initial prenatal lab tests to detect a current or previous infection.

The 1-hour glucose challenge test (GCT), also known as the gestational diabetes screen, is performed if the patient is at increased risk for gestational diabetes. The most common risk factors are obesity, first-degree relative with diabetes, and gestational diabetes with a previous pregnancy. The thyroid-stimulating hormone (TSH) level is included in the routine first prenatal visit lab tests because thyroid disease is often overlooked in women. A thyroid panel is performed if the patient has thyroid disease.

Laboratory Test	Obstetric Purpose	Expected Results
Blood type, Rh, and antibody screen	Rule out isoimmunization Risk for ABO incompatibility	Blood type: A, B, AB, O Rh: negative or positive Antibody screen: negative
CBC	Rule out the presence of infection, anemia, or thrombocytopenia	All values are normal
Rubella titer	Determine immune status	1.0 or greater indicates immunity
Hepatitis B and C	Determine history of hepatitis, current infection, or chronic hepatitis infection	Negative
Sexually transmitted infections
HIV	Diagnosis	Negative
Syphilis	Diagnosis	Negative
Gonorrhea and chlamydia	Diagnosis	Negative
Urinalysis	Rule out or diagnose a UTI	Within normal limits (WNL)
Urine C&S	Rule out or diagnose a UTI	Negative
UDS	Diagnose substance use/abuse	Negative
Genetic screening
Sickle cell screen	Screening for fetal risk for genetic conditions	Negative
Cystic fibrosis	Screening for fetal risk for genetic conditions	Negative
Cell-free DNA	Screening for fetal risk for genetic conditions	Negative for trisomy 21, 18, and 13 and sex chromosome abnormalities
Additional laboratory tests
Pap	Screen for cervical cancer	Normal cytology
Glucose screen (glucose challenge test, or GCT)	Screen for gestational diabetes	Less than 140 mg/dL
CMP	Screen for electrolyte imbalance, liver and renal function	All values are normal
TSH	Screen for thyroid function	Normal value
Thyroid function panel	Check for normal thyroid function	Normal values
Herpes simplex antibodies	Determine history of or current infection	Negative

Table 11.4 First Prenatal Visit Laboratory Tests

Patient Education at the First Prenatal Visit

The patient education provided at the first prenatal visit focuses on health maintenance and prevention of complications of pregnancy. The major education topics include the following:

• embryonic and fetal growth and development
• health promotion and lifestyle activities
• physiologic changes during early pregnancy
• psychologic changes during early pregnancy
• common discomforts of pregnancy
• signs of complications
• laboratory testing and results
• schedule of routine prenatal care visits

The nurse should sit down with the patient and discuss these topics directly rather than expecting the patient to review a lot of written material. Patients who are pregnant are typically very open to education, especially if this is going to be the patient’s first child.

Nutrition

Pregnancy changes a person’s nutritional needs, and these needs change as the weeks of gestation progress. The patient needs to consume between 70 and 100 grams of protein daily (depending on the patient’s BMI and weeks of gestation), 1,000 mg of calcium daily if 19 or more years old (1,300 mg if less than 19 years of age), 600 mcg of folate every day, and 27 mg of iron each day when pregnant (ACOG, 2022). The patient also needs to drink eight to twelve 8-ounce glasses of water every day throughout the pregnancy. See Table 11.5 for essential nutritional needs during pregnancy and the best food sources to meet these needs.

Nutrient	Daily Amount	Food Sources	Fetal and Patient Need
Protein	70 g, weeks 0–14 80 g, weeks 14–28 100 g, weeks 28–42	Eggs, almonds, poultry, red meat, fish, lentils, dairy products, peanuts	Provides major elements in the structure of all cells; building blocks of muscles and bones; build and repair the body
Calcium	1,000 mg (> 19 yr) 1,300 mg (12–19 yr)	Dairy products, dark green leafy vegetables	Bones and teeth
Folate	600 mcg	dark green leafy vegetables, beans, peanuts, fresh fruit and juice	Prevents neural tube defects Supports overall growth and development of the fetus and placenta
Iron	27 mg	Organ meats, dark green leafy vegetables, legumes, lentils, iron-fortified breads and cereals	Helps RBCs to carry oxygen and formation of fetal RBCs and additional RBC volume of the pregnant person
Vitamin B6	1.9 mg	Milk, carrots, spinach, bananas, eggs, tuna	Nervous system development and function Breakdown of fats, carbohydrates, and proteins
Vitamin B12	2.6 mcg	Poultry, fish, meat, dairy products (vegans need to take a supplement)	Helps in the formation of additional RBCs in the pregnant person and fetus Helps uphold the nervous system
Vitamin C	85 mg (> 19 yr) 80 mg (12–19 yr)	Citrus fruits, tomatoes, cruciferous vegetables	Collagen formation for bones and tendons Tissue growth and repair
Vitamin D	600 international units	Dairy products, dark green leafy vegetables	Bones and teeth
Vitamin A	770 mcg (> 19 yr) 750 mcg (12–19 yr)	Green leafy vegetables, orange and yellow vegetables	Development of the eyes and other organs in the fetus
Choline	450 mg	Eggs, peanuts, soy	Neural tube development
Iodine	220 mcg	Seafood, eggs, and iodized salt	Brain development
Docosahexaenoic acid (DHA)	200 mg	Fish and seafood	Building block of brain and retina Reduces the risk for preterm birth

Table 11.5 Essential Nutritional Needs during Pregnancy

A patient’s daily caloric intake during pregnancy is based on their BMI, activity level, and weeks of gestation. A pregnant person with a normal BMI does not require additional calories during the first trimester of pregnancy (ACOG, 2022). What is important is for the pregnant person to make their daily intake healthy. From 14 to 28 weeks of gestation (the second trimester of pregnancy), the patient should eat around 300 more calories per day. The additional calories can be ingested by drinking two 8-ounce glasses of whole milk. From 28 weeks of gestation to delivery (the third trimester of pregnancy), the patient should eat around 400 more calories a day than when not pregnant. Eating one-half of a sandwich with the 8 ounces of milk will supply the additional calories (ACOG, 2022).

The motivation to eat healthy is typically very high for the patient who is pregnant. The nurse can provide a pamphlet on eating healthy during pregnancy or pull up the MyPlate.gov website and discuss key information on the nutritional needs during pregnancy.

Link to Learning

In addition to general nutrition information, MyPlate.gov provides specifically tailored pregnancy and breast-feeding education. The education focuses on eating healthy, planning meals, vitamins and other nutritional supplements, and food safety during pregnancy and when breast-feeding.

Weight Gain during Pregnancy

The recommended total weight gain during pregnancy is based on the patient’s BMI before conception. The recommended weight gain for patients with a normal BMI is 25 to 35 pounds. For patients whose BMI indicates they were underweight before conception, the recommended total weight gain is 28 to 40 pounds. Patients whose BMI indicates they were overweight before conception are expected to gain 15 to 25 pounds, and patients whose BMI indicates they were obese before conception are expected to gain 11 to 20 pounds (King et al., 2019). The weight gain during pregnancy is expected to begin after the first trimester of pregnancy (Table 11.6).

Pregestational BMI	Recommended Total Weight Gain	Recommended Weight Gain Each Week during the Second and Third Trimesters
Underweight: < 18.5	28–40 lb	1–1.3 lb/week
Normal weight: 18.5–24.9	25–35 lb	0.8–1 lb/week
Overweight: 25.0–29.9	15–25 lb	0.5–0.7 lb/week
Obese: ≥ 30.0	11–20 lb	0.4–0.5 lb/week

Table 11.6 Recommended Weight Gain during Pregnancy

Despite the popular notion that a pregnant person is “eating for two,” that is not really the case. If it were, 25-pound newborns would be the norm. So where does the “baby weight” go? The distribution of weight gained in pregnancy is as follows:

• breasts, 1–3 pounds
• uterus, 2 pounds
• increased fluid volume, 2–3 pounds
• increased blood volume, 3–4 pounds
• fat, 6–8 pounds
• term fetus, 7–8 pounds
• placenta, 1.5 pounds
• amniotic fluid, 2 pounds

Exercise

Exercise is recommended during pregnancy even if the patient did not exercise regularly prior to conception. For patients who exercised regularly prior to conception, 30 minutes of brisk walking or yard work 5 to 7 days a week is advised. Starting slowly is recommended for patients who did not have an exercise routine prior to conception. The patient is encouraged to exercise as little as 5 minutes per day and add another 5 minutes on a weekly basis until a total of 30 minutes each day is reached. Yoga and tai chi classes specifically for pregnant people are other good options.

Link to Learning

In addition to general exercise information, the Move Your Way website provides education specifically tailored for during and after pregnancy with fact sheets, videos, and a phone app with an interactive tool for staying active. One of the coordinators of the website is the Office of Disease Prevention and Health Promotion.

Nutritional Supplements

Prenatal vitamins (prescription and OTC) with 400 mcg of folic acid are recommended for all pregnant patients. The vitamins and minerals supplied in the tablet or gummy keep the patient’s body and fetus healthy and decrease the risk for birth defects. Although iron is an ingredient in most prenatal vitamins, some pregnant patients require additional supplemental iron. Iron tablets are available by prescription or OTC and should be taken only when recommended by the health-care provider

Pharmacology Connections

Prenatal Vitamins

Prenatal vitamins are routinely prescribed during pregnancy to meet additional requirements for supporting the pregnancy and fetal growth and development.

• Indications: pregnancy nutritional supplement
• Mechanism of Action: increases essential vitamins and minerals needed during pregnancy for a healthy body and healthy fetus
• Side Effects: nausea, abdominal cramping, constipation
• Adverse Effects: anaphylaxis
• Contraindications: known allergy to any ingredient in the tablet
• Patient Education: Take with a full glass of water or citrus juice to increase absorption. Take at night if nausea occurs. The iron in the tablet may turn stools very dark brown or black and increase the risk of constipation.
• Generic Name: prenatal vitamin
• Classification: nutritional supplement
• Dosage: one tablet by mouth daily

Supplemental water-soluble vitamins are safe during pregnancy because any excess is excreted in the patient’s urine. The fat-soluble vitamins A, D, E, and K are stored in the body, increasing the risk for toxicity. Inadequate vitamin A dietary intake has not been linked to fetal anomalies. Excess vitamin A supplements and the medication isotretinoin (Accutane) used to treat acne have been linked to cranial, heart, and facial congenital anomalies, especially when taken in the first 12 weeks of gestation (Dibley & Jeacocke, 2001).

Inadequate vitamin D dietary intake has been linked to congenital neurologic deficits and bone anomalies, specifically rickets. Excess vitamin D intake (dietary or supplemental) during pregnancy has been linked to multiple cases of fetal hypercalcemia (Moretti et al., 2019). Studies have shown that an inadequate intake of vitamin E during pregnancy increases the risk of placental vascular disorders and gestational hypertensive disorders. Excess vitamin E intake has been linked to newborn jaundice (Chen et al., 2018). So far, research on vitamin K does not support conclusions about an effect on fetal development when not enough or too much vitamin K is consumed during pregnancy (Kellie, 2017).

Inadequate patient intake of the minerals iron, selenium, copper, and zinc has been linked to an increase in risk for lower birth weights in newborns (Brough et al., 2010). Excessive iron, copper, and selenium intake has been associated with higher rates of preeclampsia, preterm delivery, and intrauterine fetal growth restriction (Georgieff et al., 2019).

Ginger, an herbal supplement shown to decrease nausea, is safe to take during pregnancy. Black cohosh and dong quai have been shown to cause preterm labor and delivery. Goldenseal is linked with an increase in newborn jaundice. Yohimbe has been linked to seizure activity, hypertension, and heart attacks. Other herbal supplements linked to adverse effects during pregnancy are saw palmetto, blue cohosh, and ephedra.

Herbal supplements and safety in pregnancy (Sarecka-Hujar & Szulc-Musioł, 2022) are discussed in Table 11.7.

Herbal Supplement	Safety in Pregnancy
Ginger	No increased risk for malformations or adverse effects on pregnancy
Peppermint	No increased risk for malformations or adverse effects on pregnancy
Echinacea	No increased risk for malformations or adverse effects on pregnancy
Blue and black cohosh	Preterm labor and delivery
Dong quai	Preterm labor and delivery
Goldenseal	Newborn jaundice
Yohimbe	Seizure activity, hypertension, and heart attacks in pregnant persons
St John’s wort	Potential genetic mutations
Ephedra	Hypertension and heart attacks in pregnant persons

Table 11.7 Herbal Supplements and Safety during Pregnancy

Over-the-Counter Medications

Minor pain relief medications such as aspirin (except for low-dose aspirin prescribed for reducing the risk of preeclampsia), ibuprofen, and naproxen are contraindicated in pregnancy unless the benefit to the patient outweighs the risk to the patient, embryo, and fetus. When not prescribed for risk reduction of preeclampsia, aspirin is contraindicated during pregnancy because it can interfere with the clotting cascade, increasing the chance of the bleeding in the patient during the perinatal period. Ibuprofen, naproxen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated at 20 weeks of gestation or later because NSAIDs can cause oligohydramnios and renal disease in the fetus and newborn (U.S. Food and Drug Administration [FDA], 2020) and is associated with premature closure of the ductus arteriosus.

Acetaminophen used to be considered safe anytime in the perinatal period. However, it has been linked with abnormal liver function in patients who have a history of chronic hypertension prior to pregnancy, patients who develop any hypertensive complication of pregnancy, and patients who exceed the recommended amount of the drug in a 24-hour (3,000 mg) or 1-week interval at any time during the pregnancy (Cano Panlagua & Amariles Muñoz, 2017). Any link between prenatal use of acetaminophen and autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) in the child has not been substantiated (ACOG, 2021b).

Medications for allergies, upper respiratory infections, and the flu are other OTC medications taken during pregnancy. Chlorpheniramine (Chlor-Trimeton), hydroxyzine (Vistaril), and dexchlorpheniramine (Polmon) are first-generation antihistamines known to be safe during pregnancy. Loratadine (Claritin) and cetirizine (Zyrtec) are second-generation antihistamines considered safe for a pregnant person to take after the first trimester (ACOG, 2021c). The decongestant pseudoephedrine (Sudafed) is not recommended for a pregnant person to take during the first trimester and is contraindicated during pregnancy in patients with hypertensive disorders because it raises the blood pressure. There is no known link between the decongestant phenylephrine (Neo-Synephrine) and fetal harm or increased complications of pregnancy.

Dextromethorphan, an antitussive, and guaifenesin, an expectorant, are found in many OTC medications for a cold. Multisymptom OTC cold or flu medications contain several different drugs. It is important for any patient to read the label on any multisymptom medication to determine its contents and not to exceed the recommended 24-hour dosage.

Whenever a pregnant person is considering taking a medication, they should consult their obstetric care provider first (Federal Drug Administration, 2021). The provider will have an informed discussion with the pregnant person regarding the benefits and risks of any current or possible prescribed and over-the-counter medication to be taken during the pregnancy.

Substance Use

Tobacco products, e-cigarettes (vaping), alcohol, marijuana, and drug use are contraindicated throughout the pregnancy. Tobacco products and vaping contain nicotine, a known vasoconstrictor that affects placental function. Tobacco products are associated with low birth weight, preterm delivery, and sudden infant death syndrome (SIDS). Drinking alcohol during pregnancy is associated with fetal alcohol spectrum disorder (FASD), affecting cognitive ability, behavior, and facial structure. Marijuana use during pregnancy has been linked to low birth weight and abnormal neurologic development in infants, and symptoms sometimes do not present until the child is of school age. Opioid and illicit substance use in pregnancy is associated with an increased risk of abortion, low birth weight, abnormal neurologic development in infants, and SIDS. In addition, illicit substance use during pregnancy is also linked with an increased risk of preterm delivery, placental abruption, intrauterine fetal demise, and withdrawal symptoms in newborn infants (National Institute of Drug Abuse [NIDA], 2020).

Safety and Environmental Concerns

The same safety concerns and environmental hazards that may affect any person can affect a person who is pregnant. These include, but are not limited to, motor vehicle accidents, pesticides, painting products, heavy metal ingestion, chemical exposure, fall risks, and work hazards.

To decrease risk of injury, seat belts should be worn whenever the pregnant person is a driver or passenger in an automobile, a passenger on an airplane, or an operator of any other type of motor vehicle. A person who is pregnant should assess their home and work environments for fall risks.

Gloves and long sleeves should be worn and only organic products used when gardening. Latex paints are recommended when painting. Exposure to paint thinners, toxic chemicals at work, or any other toxic ingredients should be avoided throughout the pregnancy. These chemical exposures are associated with an increased risk for abortion. The ingestion of mercury and lead is associated with neurologic deficits in the infant. Exposure to secondhand smoke and toxic chemicals in the air has effects on the fetus similar to those the pregnant person’s smoking would have.

Pregnant persons with cats should be reminded not to change cat litter and avoid being scratched by outdoor cats. Cat feces and nails can transport toxoplasmosis, a known infectious teratogen. Toxoplasmosis can also be transmitted through undercooked meat.

Real RN Stories

Nurse: Jamie, RN
Years in practice: 12
Clinical setting: Labor suite at not-for-profit hospital
Facility location: South Carolina

I remember one patient who was employed at an autobody shop and was at the office for her first prenatal visit. I learned the patient’s job was in the front office, greeting customers, answering the telephone, and inputting invoices and payments. The shop repaired cars damaged in motor vehicle accidents, so this meant the fumes from the paint and other chemicals came into the front office because the office was not sealed off from the workspace. Her health-care team, and the patient herself, was concerned about her exposure to the fumes, and it was recommended that she go on personal leave or quit her job. The patient then discussed her concerns with her boss, the owner of the autobody shop, who arranged for her to work from home. The patient was able to keep working during the pregnancy and is still employed at the autobody shop, working 2 days in the office and 3 days at home to spend more time with the baby, who is now 2 years old.

Signs of Pregnancy Complications

As discussed in Chapter 10 Pregnancy, the list of common discomforts of pregnancy is a lengthy one. Not surprisingly, it is not always easy for a person who is pregnant to determine if a symptom is expected and related to the pregnancy or is a sign of a pregnancy complication. The nurse investigates the symptoms to differentiate between symptoms that are expected, those that indicate the presence of a medical condition requiring evaluation and treatment, and those that indicate an obstetric complication or emergency requiring immediate evaluation. Symptoms associated with complications of pregnancy discussed at the first prenatal visit are listed in Table 11.8.

Symptom	Possible Complication
Persistent vomiting	Hyperemesis gravidarum
Dysuria	UTI
Intermittent back pain, pelvic pressure	Pyelonephritis or preterm labor
Vaginal bleeding	Abortion, placenta previa, or placental abruption; cervicitis
Temperature >38.3° C (101° F)	Infection
Persistent abdominal pain, epigastric pain	Cholelithiasis, liver disease, gastroesophageal reflux disease (GERD), preeclampsia, and HELLP (syndrome with hemolysis, elevated liver enzymes, and low platelet counts)
Frequent dizziness	Anemia, dehydration, infection, heart disease
Leaking of fluid from the vagina	Vaginitis, premature rupture of membranes (PROM)

Table 11.8 Signs of Pregnancy Complications Discussed at the First Prenatal Visit

Nausea and vomiting frequently occur in the first trimester of pregnancy and are considered normal. Persistent vomiting accompanied by weight loss is not normal, and the patient needs to be evaluated for dehydration or hyperemesis gravidarum. Intravenous fluids and antiemetics may be needed.

Increased frequency in urination is also considered normal during pregnancy because of the pressure the growing uterus places on the bladder. Dysuria and hematuria are symptoms of a urinary tract infection (UTI), and the patient needs to be evaluated and treated. An untreated simple UTI can progress to pyelonephritis, triggering preterm contractions.

Intermittent back pain and pelvic pressure are common during pregnancy. The pelvic pressure is due to the weight of the growing uterus. The intermittent back pain is due to changes in the curvature of the spine because of the weight of the growing uterus. Intermittent back pain and pelvic pressure can be a sign of preterm contractions or UTI, and both need to be evaluated and treated as needed.

Vaginal bleeding is never a normal symptom during pregnancy and always requires evaluation. Vaginal spotting may occur from a vaginal exam by the health-care provider, from simple cervical erosion due to vaginitis, or from the penis coming in contact with the cervix during intercourse. Vaginal spotting and bleeding may indicate that a possible abortion, preterm labor, placenta previa, or hidden placental abruption is occurring.

When a person has a temperature >38.3° C (101° F), an infection is present. The cause of the infection needs to be established to determine if there is any possibility of injury to the pregnant patient, fetus, or both. A temperature >38.3° C (101° F) that is accompanied by nausea and vomiting can lead to dehydration and preterm birth.

Pregnant patients often experience occasional epigastric or abdominal pain. This pain can be as simple as dyspepsia or flatus. However, epigastric pain may also indicate cholelithiasis or hepatic inflammation; both are associated with hypertensive disorders of pregnancy. Abdominal pain can be a sign of placental abruption, appendicitis, or a gastrointestinal infection.

The patient may experience an occasional dizzy spell in the early weeks of the pregnancy. Dizziness may indicate a drop in blood glucose or blood pressure. Frequent episodes of dizziness may indicate anemia, dehydration, or an underlying heart condition.

Leaking of fluid from the vagina may be stress incontinence or may indicate vaginitis. Fluid leaking from the vagina is also a sign of spontaneous rupture of the membranes (SROM). When the membranes rupture in the first trimester, an abortion is inevitable.

Follow-up

The final topic the nurse discusses with the patient is when to return to the office or clinic for the remainder of the pregnancy. During the first 28 weeks of gestation, prenatal follow-up appointments are scheduled every 4 weeks. In the third trimester, follow-up prenatal visits occur every 2 weeks from 28 to 36 weeks. Starting at 36 weeks of gestation, follow-up visits are scheduled weekly until the patient goes into labor. This interval schedule is kept as long as there are no signs of patient or fetal complications. The follow-up visits are scheduled more frequently if early signs or a diagnosis of a complication of the pregnancy occurs.