Chronic illnesses in patient or family members

An accurate history is essential for assessing the pregnant woman's health. It also shapes the order and content of the physical examination, which is directed primarily to confirming the woman's suspicion of pregnancy. The woman will usually have many questions for you about her pregnancy and seek understanding of her symptoms.

During the initial visit, focus the history on the woman's current state of health and on risk factors for any conditions that could adversely affect her or the developing fetus. Ask about symptoms of pregnancy such as breast tenderness, nausea or vomiting, urinary frequency, change in bowel habits, and fatigue (see table on p. 412). Review her attitude toward the pregnancy, and if she plans to continue to term. Look into her eating patterns and quality of nutrition. Does she smoke or drink alcohol? What about her income and her social support network?

Although best identified and addressed before conception, are there any sources of high-level stress? If she works, has there been any exposure to ter-atogenic drugs or toxic substances? What about any use of illicit drugs? Is there any history of domestic violence that may escalate during pregnancy?

What about prior pregnancies, since past obstetrical problems tend to recur? Has she had any major complications of pregnancy or problems with labor or delivery? Has she had a premature or growth-retarded infant? Ask also about her past medical history, especially any chronic diseases like hypertension, diabetes, or cardiac conditions. You should also review her family history for these conditions.

In addition, the clinician should get information needed for calculating the expected weeks of gestation by dates. This is currently counted in weeks from either (1) the first day of the last menstrual period (LMP), known as men strual age, or (2) the date of conception, if this is known (conception age). Menstrual age is used most frequently to express the weeks of gestation calculated by dates. The first day of the LMP is also used to calculate the expected date of confinement (EDC) or projected time of term labor and birth for women with regular 28- to 30-day cycles. The EDC can be determined by adding 7 days to the first day of the LMP, subtracting 3 months, and adding one year (Naegele'srule). This information is often one of the first questions the pregnant woman asks when seeking confirmation of pregnancy.

The weeks of gestation at the time of examination tell you the expected size of the uterus if the LMP was normal, the dates were remembered accurately, and conception actually occurred. You should estimate this size before examining the woman. You can then compare the expected size by dates with what you actually palpate during the bimanual examination, or abdominally, if pregnancy is beyond 14 weeks of gestation. Uterine size is measured by the palpable size of the uterus if still within the pelvic cavity, or by the height of the fundus if above the symphysis pubis. If there is a discrepancy, you need to look for the causes. Accurately dating the pregnancy is best done early, and contributes to good decision-making later in pregnancy if the fetus is not growing well, if preterm labor is suspected, or if the pregnancy goes beyond 42 weeks of gestation. If the woman does not remember her LMP or has irregular menstrual cycles, dating the pregnancy is done by palpation and subsequent monitoring of the growth curve (see p. 410) along with the time of first fetal movements. In some cases, ultrasound is an appropriate adjunct for dating an early pregnancy.

As you begin preparing the patient for the physical examination, ask the woman if she has ever had a complete pelvic examination. If not, take the time to explain what is involved and seek her cooperation for each of its components. Explaining what you do and what you find is important if you are to strengthen rapport and help her to understand the changes in her body and its response to pregnancy, and how she can best maintain her health. Be sure to ask in a sensitive and confidential manner if she has ever experienced a sexual assault, since this may cause her to resist any examination of the pelvis.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

Get My Free Ebook

Post a comment