QUESTIONS TO ANSWER ON THIS WRITE-UP
1) Explain how sociocultural factors might impact the care plan for patients in the case study your colleagues selected.
2) Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or contrasting perspectives
You are seeing a 28-year-old African American female, G6 P 3115, who is currently on oral combined hormonal contraception. She is here because she and her partner would like to have another child. She heard, “it takes a while to become pregnant after being on the Pill,” so she discontinued them three months ago. They have not been using any contraception since then. Upon questioning, she states that on the Pill, sometimes her menstrual periods are very light, and once she did not have one at all. Her urine pregnancy test in the clinic is positive. Her LMP was 7-14-12. You are seeing her on 12-3-12.
Her recent use of hormonal contraceptives may lead to an incorrect calculation of the date of her last menstrual period (LMP). Along with her history of her irregular menstrual patterns, including missed periods, predicting her due date presents a challenge. A simple method of pregnancy dating is Naegele’s rule, which is calculated by counting back three months from the LMP and adding seven days (Schuiling & Likis, 2017). This method is most precise when the patient has a 28-day menstrual cycle. Naegele’s rule would not be accurate in this situation since she has irregular menses and the fact that she was still on birth control when she did have her last period. She also reports that she discontinued her birth control three months ago; however, her LMP was nearly five months ago. Accurate dating is necessary for managing the pregnancy, especially about timing interventions and monitoring fetal growth. Therefore, we would perform an ultrasound to date the pregnancy.
According to MacKenzie, Stephenson, and Funai,(2019), an ultrasound is recommended for the estimation of gestational age when menstrual cycles are irregular, LMP is unknown or uncertain, the patient conceived while using hormonal contraception, or the uterine size on physical examination contrasts from that predicted by the LMP. Choices of sonogram technique are transvaginal (TVS) and the transabdominal (TAS). MacKenzie, Stephenson, and Funai (2019) indicate that TVS provides clear and accurate images in the earliest stages of pregnancy, while TAS may be unable to detect an intrauterine gestation. Therefore, TVS is recommended for the evaluation of the gestational sac and other early embryonic structures. Measurement of the crown-rump length via TVS is the most accurate method of estimating gestational age in the first trimester (MacKenzie, Stephenson, & Funai, 2019).
Prenatal care is beneficial when initiated in the first trimester, ideally by ten weeks of gestation, since there are some screening and diagnostic tests that can be performed at this gestational age. It is essential at this initial meeting to get a thorough history and physical. This includes family, genetic, and obstetric history. As noted in the case study, this is her seventh pregnancy, one of which was preterm and one that she lost. MacKenzie, Stephenson, and Funai (2019) indicate that a poor outcome in a previous pregnancy increases the risk of a poor outcome in the next pregnancy. Appropriate clinical procedures and screening guidelines for this patient start with a baseline blood pressure, weight, height, and BMI. These are important for the management of care. A set of labs should be obtained at this first prenatal visit including a complete blood count (CBC), blood type, urinalysis, urine culture, rubella and varicella immunity, hepatitis B and C, sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and tuberculosis (Women’s Health Care Physicians [WHCP], 2019). She should also be screened for tobacco, alcohol, and illicit drug use, as well as intimate partner violence (Tharpe, Farley, & Jordan, 2017). Genetic screening and a first-trimester ultrasound examination can lead to earlier detection of fetal malformations and of multiple pregnancies (MacKenzie, Stephenson, & Funai, 2019). The Centers for Disease Control and Prevention [CDC] (2019) recommends starting her on a prenatal vitamin with iron and folic acid. Since this is flu season, she should also be offered an influenza vaccination.
A plan of care for the patient includes prenatal visits every four weeks until 28 weeks of gestation, every two weeks from 28 to 36 weeks, and then weekly until delivery (Schuiling & Likis, 2017). She is considered higher risk since she had a preterm birth and a miscarriage or abortion; therefore, she should stay on this typical visit schedule or more frequently, and she may need to see an obstetrician. Routine assessments at each second and third-trimester prenatal visits typically consist of vital signs, weight, fetal growth measurement, auscultating fetal heart tones, assessing fetal activity, assessment of fetal presentation, and a review of any concerns or issues the patient might have (Lockwood, & Magriples, 2019). At 15 to 24 weeks of gestation, women have the option of screening for neural tube defects, trisomy 21, ultrasound screening for fetal structural anomalies, and cervical length screening (Lockwood & Magriples, 2019). Between 24 to 38 weeks gestation, a glucose challenge test to screen for gestational diabetes is performed and screening for anemia (Schiuling & Likis, 2017). Tdap should be administered during this time as well, for passive antibody transfer to the newborn. All pregnant women are screened at 35 to 37 weeks of gestation for group B beta-hemolytic streptococcus (GBS) colonization with swabs of both the lower vagina and the rectum (Lockwood & Magriples, 2019).
Even though this patient has had six previous pregnancies, she should still receive education and close guidance. Education for this patient would include when to call a provider or seek medical care. This includes vaginal bleeding or a change in discharge, leakage of fluid from the vagina, fever, pain, acute shortness of breath, calf or leg pain, headache, dysuria, uterine contractions, and decreased fetal activity after the fetal activity has become established (Lockwood & Magriples, 2019). Other health behaviors include eating a healthy diet, continuing to wear a seat belt, physical activity for 30 minutes daily on most days, routine dental care, avoiding hot tubs and saunas, and avoiding alcohol, tobacco, and illicit drug (Lockwood & Magriples, 2019). She should receive a list of allowable medications. Plans should be discussed regarding labor and delivery.
References
The Centers for Disease Control and Prevention. (2019). During Pregnancy. Retrieved from https://www.cdc.gov/pregnancy/during.html.
Lockwood, C., & Magriples, U. (2019). Prenatal care: Second and third trimesters. https://www.uptodate.com/contents/prenatal-care-second-and-third-trimesters
MacKenzie, A., Stephenson, C., & Funai, A. (2019). Prenatal assessment of gestational age, date of delivery, and fetal weight. https://www.uptodate.com/contents/prenatal-assessment-of-gestational-age-date-of-delivery-and-fetal-weight
Schuiling, K., & Likis, F. (2017). Women’s Gynecologic Health (3rd ed.). Burlington, MA: Jones & Bartlett Learning.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.
Women’s Health Care Physicians. (2019). Retrieved from https://www.acog.org/Patients/FAQs/Routine-Tests-During-Pregnancy#are.