11.3: Care in the First Trimester of Pregnancy
By the end of this section, you will be able to:
- Analyze the subjective and objective patient data obtained in the interval history since the previous prenatal visit during the first trimester
- Explain the purpose of the laboratory tests obtained during the first trimester
- Provide the patient education during the first trimester
The second prenatal visit is often the only follow-up visit in the first trimester, especially if the first prenatal visit was at 8 weeks of gestation. Follow-up visits are less time intensive for the patient. The patient signs in when they arrive at the office or clinic and waits for the nurse to call their name to obtain the intake data. The patient next has a limited exam and visit with the health-care provider relevant to the weeks of gestation. After the exam, lab work is performed (if indicated), and then the patient receives additional education from the nurse before scheduling the next follow-up prenatal visit.
The Centering Healthcare Institute provides a health-care model that builds healthy communities through increased access to health care, empowerment, education, and combating isolation and vulnerability. Persons who are pregnant and their support person meet in groups of 8 to 12 at the time of a routine prenatal visit with the health-care provider to discuss patient concerns and learn about pregnancy and risk factors. Research has demonstrated that the centering approach results in increased birth weights, increased success with breast-feeding, and decreased risk of preterm birth.
Interval History Data
Before calling the patient back to begin the interval history , the nurse reviews the patient’s EHR. Most offices and clinics providing prenatal care have a method of documenting pertinent data to assist in the chart-review process, especially when multiple health-care providers are performing prenatal care. This list of data (sometimes called the problem list) assists with continuity of care and early identification of risk factors and complications throughout the pregnancy. The pertinent data are added to the list as needed at each subsequent prenatal visit and include the following:
- age
- gravida and para
- EDD
- complications of current pregnancy
- current medical conditions
- previous obstetric and gynecologic surgeries
- previous complications of pregnancy
- blood type and Rh
- date of antepartum Rho(D) immune globulin (RhoGAM) injection (if applicable)
- rubella status
- positive STI test results
-
integrated and multiple marker screening results
- cell-free DNA results (if applicable)
- amniocentesis results (if applicable)
- diabetes screening results
- GBS results
- family considerations
The nurse next calls the patient into the examination area, weighs the patient, and takes the patient’s blood pressure. The nurse discusses the normal laboratory results from the first prenatal visit with the patient at this time. Abnormal results are usually discussed by the health-care provider with the patient. The interval history is obtained next. The nurse asks the patient if they are currently experiencing any of the following symptoms or have experienced them since the previous prenatal visit:
- vaginal discharge, bleeding, or leaking of fluid
- epigastric or abdominal pain
- pelvic pressure or uterine cramping
- back pain or dysuria
- dizziness or syncope
- headache
If the nurse is the health-care provider and the patient responds yes to any of the symptoms, the nurse asks follow-up questions and determines if any additional testing needs to be ordered. If the patient has not already provided a urine specimen, the nurse asks them to provide one before going into the exam room. The urine is tested for glucose, protein, nitrites, blood, and ketones by dipstick when indicated by the interval data and physical exam.
Physical Exam
The physical exam at the second prenatal visit consists of documenting the location of the uterus and auscultating the fetal heart rate. If the patient is at 12 or more weeks of gestation, the fundus can be palpated. The fetal heart rate is expected to be 110 to 160 beats per minute. If the patient responded yes to any of the symptoms at the interval history, relevant data are obtained at this time, such as vaginal discharge or bleeding, and are reported to the health-care provider. The data obtained during the interval history and the physical exam results are documented in the EHR and include the following:
- date of visit
- week of gestation
- weight
- blood pressure
- urine dipstick (when indicated)
-
interval history
- vaginal bleeding
- vaginal discharge or leaking of fluid
- nausea and vomiting
- epigastric discomfort
- uterine cramping or contractions
- lower back discomfort
- suprapubic discomfort
- dysuria
- headache
- dizziness or syncope
- fundal height
- fetal movement
- edema
- other
Laboratory Tests
Important laboratory tests performed in the first and second trimester s of pregnancy to determine if there is an increased risk for aneuploidy and neural tube defects in the fetus are called integrated or sequential screenings . The first of the two integrated screens is performed at 10 to 13 weeks of gestation and includes a blood test and an ultrasound . The second integrated screen includes only a blood test and is performed at 15 to 22 weeks of gestation. As the word screening implies, these tests are performed to determine risk for, not to diagnose, an abnormality in the fetus. The integrated screenings are discussed in more detail in Chapter 13 Prenatal Testing (ACOG, 2019).
After the nurse informs the patient of the purpose of the screen, the patient decides if they want the testing to be performed. The screen is encouraged for patients with risk factors for delivering a baby with chromosomal abnormalities, such as the patient who is more than 35 years old, and is available to all pregnant persons. Some patients choose not to have the screen done based on religious or personal choice or choose to rely on the second trimester fetal anatomy ultrasound to rule out an anomaly in the fetus.
Education in the First Trimester
Education in the first trimester of pregnancy focuses on fetal growth and development, nutrition, common discomforts of pregnancy, and signs of complications. At 12 weeks of pregnancy, the fetus is still vulnerable to teratogens , and the nurse should reinforce the importance of a healthy lifestyle. If the patient is a smoker, the nurse should determine if the patient has stopped or decreased cigarette smoking. When reviewing the signs of complications of pregnancy , it is important for the nurse to stress when to call the health-care provider.