CHAPTER 8
THE GYNECOLOGIC EXAMINATION
AND PRENATAL CARE
PRETEST
True or False
1. A complete gynecologic examination consists of a
breast examination and a pelvic examination.
2. The American Cancer Society recommends that a
woman perform a breast self-examination weekly.
3. The purpose of the Pap test is for the early detection
of cervical cancer.
4. The patient should be instructed to douche before
having a Pap test.
5. Trichomoniasis produces a profuse frothy vaginal
discharge.
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PRETEST, CONT.
True or False
6.
Another name for candidiasis is a yeast infection.
7.
Prenatal refers to the care of the pregnant woman
before delivery of the infant.
8.
During each return prenatal visit, the mother's urine
is tested for glucose and protein.
9.
The normal range for the fetal pulse rate is between
120 and 160 beats per minute.
10. Amniocentesis can be used to diagnose certain
genetically transmitted conditions.
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Content Outline
Introduction to the Gynecologic Examination
and Prenatal Care
1. Gynecologic examination: frequently
performed in medical office
2. Prenatal care: series of scheduled visits
a. Purpose: To promote health of mother and
fetus during pregnancy
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Introduction to the Gynecologic
Examination and Prenatal Care
3. Responsibilities of MA: for gynecologic
examination and prenatal care
a. Explain purpose of procedures to patient
•
Makes examinations proceed more smoothly
Makes patient more comfortable
b. Assist with examinations and treatments
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Gynecology
1. Gynecology: The branch of medicine that
deals with diseases of the reproductive organs
of women
2. Gynecologic examination includes:
a. Breast examination
b. Pelvic examination
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Gynecology, cont.
3. Purpose of Gynecologic examination
a. Assess health of reproductive organs
•
To detect early signs of disease
– Leads to early diagnosis and treatment
b. To reduce apprehension/embarrassment
during examination:
•
Fully explain procedure to patient
•
Offer to answer questions
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Female Reproductive System
Modified from Thibodeau GA, Patton KT: Anatomy and physiology, ed 4, St. Louis, 1999, Mosby.
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Terms Related to Gynecology
1. Amenorrhea: The absence or cessation of
the menstrual period
a. Normally occurs:
•
Before puberty
•
During pregnancy
•
After menopause
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Terms Related to Gynecology, cont.
2. Cervix: The lower narrow end
of the uterus that opens into the
vagina
3. Colposcopy: Examination of
the cervix using a colposcope
F
r
o
From Apgar BS, Brotzman GL, Spitzer M:
Colposcopy: principles and practice-an
integrated textbook and atlas, Philadelphia,
2002, Saunders.
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Terms Related to Gynecology, cont.
4. Dysmenorrhea: Pain associated with the
menstrual period
5. Dyspareunia: Pain in the vagina or pelvis
experienced by a woman during intercourse
6. Dysplasia: The growth of abnormal cells
a. Precancerous condition: May or may not
develop into cancer
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Terms Related to Gynecology, cont.
7. Menopause: The permanent cessation of
menstruation
a. Usually occurs between ages 45 and 55
b. Average age of 51
8. Menorrhagia: Excessive bleeding during the
menstrual period
a. In the number of days or amount of blood or
both
b. Also called dysfunctional uterine bleeding
(DUB)
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Terms Related to Gynecology, cont.
9. Metrorrhagia: Bleeding between menstrual
periods
10.Perimenopause: phase prior to the onset of
menopause
a. Regular periods change to irregular menstrual
cycles
b. Increased periods of amenorrhea
11.Perineum
a. Female: region between vaginal orifice and
anus
b. Male: region between scrotum and anus
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Terms Related to Gynecology, cont.
12. Risk factor: Anything that increases an
individual's chance of developing disease
a. Some can be avoided
•
Example: smoking
b. Some cannot be avoided
•
Examples: age and family history
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The Breast Examination
1. Physician usually begins gynecologic
examination with breast examination
2. Patient position: supine
3. Breast and nipples inspected for:
a. Swelling
b. Dimpling
c. Puckering
d. Change in skin texture
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The Breast Examination, cont.
4. Nipples checked for abnormalities such
as:
a. Bleeding
b. Discharge
5. Breast and axillary lymph nodes
palpated for:
a. Lumps
b. Hard knots
c. Thickening
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The Breast Examination, cont.
6. Breast self-examination (BSE)
a. MA responsible for teaching BSE to patient
b. Most breast cancers discovered by patient
during BSE
c. American Cancer Society recommends:
•
Women 20 and older: perform a BSE every
month
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The Breast Examination, cont.
d. If lump or other change is discovered:
schedule appointment
e. Most breast lumps not cancerous (80%)
•
Physician must make that diagnosis
•
See Highlight on Breast Cancer
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The Pelvic Examination
1. Purpose
a. Assess reproductive organs:
•
Size
•
Shape
•
Location
b. Detect presence of disease
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The Pelvic Examination, cont.
2. Consists of:
a. Inspection of external genitalia, vagina, and
cervix
b. Collection of a specimen for a Pap test
c. Bimanual pelvic examination
d. Rectal-vaginal examination
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The Pelvic Examination, cont.
3. Patient position: lithotomy
a. Patient lies on table on back
b. Feet in stirrups and buttocks
at bottom edge of table
c. Stirrups should be
level with table
•
Pulled out 1 foot
from table
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The Pelvic Examination, cont.
d. Patient's knees should be bent and relaxed
•
Thighs rotated outward as far as comfortable
e. Lithotomy position:
•
Helps relax vulva and perineum
•
Facilitates insertion of vaginal speculum
f. Difficult position to maintain
•
Do not put in position until physician is ready
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The Pelvic Examination, cont.
4. Properly drape patient
a. Reduces exposure
b. Provides warmth
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The Pelvic Examination, cont.
5. MA should help patient relax
a. Breathe deeply, slowly, and evenly through
mouth
•
Easier to insert speculum
•
Easier to perform bimanual examination
•
More comfortable for patient
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The Pelvic Examination, cont.
6. MA should remain in room during
examination to:
a. Provide legal protection for physician
b. Reassure patient
c. Assist physician
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Inspection of the External Genitalia,
Vagina, and Cervix
1. Vulva inspected for:
a. Swelling
b. Ulceration
c. Redness
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Vaginal Speculum
2. Vaginal speculum
a. Available in two forms:
•
Metal speculum: reusable
– Must be sanitized and sterilized after use
•
Plastic speculum: disposable
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Vaginal Speculum, cont.
b. Sizes: size used based on physical and
sexual maturity of patient
•
Small
•
Medium
•
Large
Courtesy Elmed, Addison, IL.
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Vaginal Speculum, cont.
c. Function of vaginal speculum: hold vagina
apart
•
Allows for visual inspection of vagina and cervix
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Vaginal Speculum, cont.
d. Metal speculum can be warmed by:
•
Placing on a heating pad
•
Storing in a warming drawer
e. Warmed speculum: more comfortable for pt
•
Do not overheat speculum
•
Speculum that is too hot: uncomfortable for pt
f. Disposable plastic speculum: can use at
room temperature
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Vaginal Speculum, cont.
g. Pap test (direct smear method): do not
lubricate speculum
•
Will interfere with test results
•
Can be moistened with warm water
•
Helps to lubricate: facilitates insertion
h. Pap test (liquid-based method): lubricate
speculum with water-based lubricant
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Inspection of the External Genitalia,
Vagina, and Cervix
3. Speculum inserted and vagina and
cervix inspected for:
a. Color
b. Lacerations
c. Ulcerations
d. Tenderness
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Inspection of the External Genitalia,
Vagina, and Cervix, cont.
e. Nodules
f. Discharge
g. If abnormal discharge present:
•
Specimen obtained for microbiologic
examination
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The Pap Test
1. Consists of a cytology evaluation
a. Named after developer: Dr. George
Papanicolaou
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The Pap Test, cont.
2. Used for:
a. Early detection of cervical cancer
•
Almost all cervical cancers can be cured if
detected early
b. Detection of abnormal (atypical) cells of
cervix
•
Might develop into cancer if not treated
c. Detection of cancer of endometrium (less
reliable in doing so)
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The Pap Test, cont.
3. American Cancer Society recommends:
a. Annual Pap and pelvic examination:
•
Beginning within 3 years after having
intercourse or age 21
– Whichever is earlier
b. Direct smear Pap test: perform every year
c. Liquid-based Pap test: perform every 2
years
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The Pap Test, cont.
d. After three or more consecutive negative
tests:
•
May be screened every 2 to 3 years
e. Should have Pap test every year:
•
•
Women at high risk for cervical cancer
–
Diethylstilbestrol (DES) exposure before birth
–
Human immunodeficiency (HIV) infection
–
Weakened immune system (organ
transplantation, chemotherapy, chronic steroid
use)
Women who have had previous abnormal Pap
results
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The Pap Test, cont.
4. Patient Instructions
a. Do not schedule test during menstrual
period
•
Red blood cells obscure specimen:
– Interfere with accurate evaluation
b. Schedule test 10 to 20 days after first day of
last menstrual period
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The Pap Test, cont.
c. Do not douche or insert tampons, meds or
spermicides into vagina for 2 days before test
•
Douching and tampons: reduces number of cells
available for analysis
•
Vaginal meds/spermicides: change pH of vagina
(makes test invalid)
d. Abstain from intercourse: for 2 days before
Pap test
•
Can produce inflammatory changes
•
Obscures visualization of abnormal cells that may
be present
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The Pap Test, cont.
5. Specimen Collection
a. Sample of squamous epithelial cells
collected
•
Squamous epithelial cells: thin, flat layer of cells
located on outermost layer of cervix
b. Scraping of cells taken from:
•
Ectocervix
•
Endocervix
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The Pap Test, cont.
•
Can also be taken from vagina:
– Not usually done unless:
1) A lesion is observed
2) Maturation Index to be determined
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Vaginal Specimen
c. Obtaining Pap specimen
•
Vaginal Specimen (if needed)
– Collected first
– Rounded end
of spatula
used
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Vaginal Specimen, cont.
– Types of vaginal specimens collected:
1) Routine specimen: collected from
vaginal pool in the posterior fornix of
vagina (just below cervix)
2) Specimen from
lesion: cells
collected from
lesion
3) Maturation
index: collected
from upper third
of lateral vaginal
wall
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Cervical Specimen
•
Cervical Specimen
– S-shaped end of spatula used
(1) Placed just inside cervical canal
- Blade rotated 360 degrees over surface of
ectocervix at the squamocolumnar junction
(where cervical cancer is most often found)
-Ectocervix: Part of the cervix that projects
into the vagina
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Cervical Specimen
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Endocervical Specimen
•
Endocervical Specimen
– Endocervical brush used
– Specimen collected from endocervical canal
– Brush inserted into canal and rotated
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Endocervical Specimen
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Pap Smear Method
6. Preparation Methods
a. Direct Smear (Pap smear)
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Pap Smear Method, cont.
•
Specimen spread evenly on a glass slide with a
frosted edge
•
Slide labeled according to source of specimen:
– V: vaginal
– C: cervical
– E: endocervical
– (Slides also available that are divided into
thirds prelabeled with V, C, and E)
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Pap Smear Method, cont.
•
Fix smears immediately with 95% ethyl alcohol
or cytology fixative spray
– Fix slides before they dry: avoids inaccurate
results
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Pap Smear Method, cont.
– Purpose of fixative
1) Maintain normal appearance of cells
2) Protect slides from contaminants (dust,
bacteria)
3) Firmly attaches smear to slide
•
Allow slides to dry thoroughly
•
Place slides in slide container
– Protects during transport
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Liquid-Based Method, cont.
b. Liquid-Based
Preparation
•
Brand
names:
Ectocervix
– Thin Prep
Pap test
– AutoCyte
Pap test
– SurePath
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Liquid-Based Method
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Liquid-Based Method, cont.
•
More expensive than direct smear
method
•
Better quality spec obtained
•
–
Results in fewer slides that are
unsatisfactory for evaluation
–
Reduces false-negative results
Specimen collection (for V, C, and E):
–
Can be collected same way as for direct
smear method
(1) Vaginal specimen (if collected): Rounded
end of spatula
(2) Ectocervical specimen: S-shaped end of
spatula
(3) Endocervical specimen: Endocervical
brush
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Liquid-Based Method, cont.
•
Plastic broom: can also be used to collect
specimen
– Central bristles inserted into endocervical
canal
1) Inserted deep enough to allow shorter
bristles to fully contact outside of cervix
– Broom gently pushed and rotated clockwise
five times
1) Advantage: specimens from both
ectocervix and endocervix canal
collected at same time
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Broom
Ectocervix
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Liquid-Based Method, cont.
•
Once specimen collected:
-Rinse collection device in a vial of liquid
preservative (Thin Prep)
-Remove tip of collection device and deposit in
liquid preservative (SurePath)
•
Purpose of preservative:
– Maintains specimen
– Prevents drying during transport to
laboratory
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Liquid-Based Method, cont.
•
After specimen received by laboratory:
– Vial placed in automated slide preparation
processor which performs the following:
1) Separates cells from debris
2) Disperses a cell sample onto a slide in a
thin uniform layer
3) Immerses slide in fixative to maintain
normal appearance of cells
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Liquid-Based Method, cont.
7. How liquid-based method provides a
better quality specimen
a. Amount of specimen
•
Direct smear method: only small portion of
specimen is smeared on slide
– Most of specimen thrown away with
collection device
•
Liquid-based method: collection device rinsed
or tip deposited in liquid
– Preserves all or most of specimen
– Laboratory has more of specimen available
to evaluate
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Liquid-Based Method, cont.
b. Debris collected along with cells (blood,
mucus)
•
Direct smear method: debris smeared on slide
along with cells
– Obscures cells: difficult to evaluate cells
•
Liquid-based method: automated processor
removes debris and transfers cells to a slide
– Provides clear view of cells
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Liquid-Based Method, cont.
c. Distribution of cells
•
Direct smear method: cells tend to clump
together
– More difficult to evaluate
•
Liquid-based method: processor disperses cell
in a thin even layer
– Cells are spread out: easier to evaluate
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Cytology Request
8. Cytology Request
a. Must accompany all
Pap specimens
b. MA responsible for
completing request
•
Assists laboratory in
evaluating specimen
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Cytology Request, cont.
c. Includes:
•
General Information
– Physician's name, address, phone
– Patient's name, address, ID number, date of
birth, last menstrual period, insurance
information
•
Date and Time of Collection: provides laboratory
with information on freshness of specimen
•
Collection Method:
– Direct smear
– Liquid-based preparation
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Cytology Request, cont.
•
Source of the Specimen:
– Identifies the source of the spec for the
laboratory
– MA checks one or more of the following:
1) Cervical
2) Endocervical
3) Vaginal
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Cytology Request, cont.
•
Collection Technique:
– Device(s) used to obtain specimen
– MA checks one or more of following:
1) Spatula
Ectocervix
2) Brush
3) Broom
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Cytology Request, cont.
•
Patient History
– Past and present health status
– Assists laboratory in evaluating the spec
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Cytology Request, cont.
– MA checks boxes that apply:
1) Pregnant
2) Lactating
3) Oral contraceptives
4) Postmenopausal
5) Hormone replacement therapy
6) Postmenopausal bleeding
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Cytology Request, cont.
7) Postpartum
8) Intrauterine device
9) Postcoital bleeding
10) DES exposure
11) Previous abnormal smear
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Cytology Request, cont.
•
Previous Treatment:
– Any treatment for precancerous or
cancerous condition of cervix
– MA checks any that apply:
1) Colposcopy and biopsy
2) Cryosurgery
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Cytology Request, cont.
3) LEEP (loop electrocautery excision
procedure)
4) Laser vaporization
5) Conization
6) Hysterectomy
7) Radiation
8) Chemotherapy
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Cytology Request
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Evaluation of the Pap Specimen
9. Evaluation of the Pap Specimen
a. Slide must be stained by lab tech before
being evaluated (for both direct smear and
liquid-based)
•
Allows better view of epithelial cells
b. Studied under microscope for
abnormalities by cytotechnologist
(specially trained technician)
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Evaluation of the Pap Specimen,
cont.
c. If abnormality present: reviewed by
cytopathologist (physician specializing in
cell pathology)
d. Findings recorded on cytology report and
sent to medical office
e. Automated cytology computer-imaging
device: examines every cell on slide
•
Selects and displays cells that are "most
abnormal"
•
These cells are further evaluated by
cytotechnologist
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Evaluation of the Pap Specimen,
cont.
10.Maturation Index (MI): endocrine evaluation
a. Performed on cells taken from lateral vaginal
wall
b. Purpose:
•
Assists in evaluating cause of:
•
Infertility
•
Menopausal or postmenopausal bleeding
•
Amenorrhea
•
Assess results of treatment with hormones
c. Must check MI box on request form
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Cytology Report
11.Cytology Report
a. Bethesda system: used to report Pap test
results
•
Developed by National Cancer Institute in
Bethesda, MD
•
Provides a detailed description rather than
numerical result (as with previous class I
through V system)
b. Cytology report includes:
•
Specimen Type: Pap smear or liquid-based
(Thin-Prep)
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Cytology Report, cont.
•
Specimen Adequacy: refers to the quality of the
specimen
– Satisfactory for Evaluation
1) Sufficient sampling for assessment
2) Sufficient quality for assessment
– Unsatisfactory for Evaluation
1) Sampling or quality was inadequate
2) Reason is given (e.g., too few cells)
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Cytology Report, cont.
•
General Categorization
– Provides a quick review of the report
1) Negative for Intraepithelial Lesion or
Malignancy
2) Cells were normal:
a) No precancer or cancer
b) Benign changes present (e.g.,
vaginal infection)
c) Described in detail in
Interpretation/Result section
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Cytology Report, cont.
3) Epithelial Cell Abnormality
a)
Abnormal cell changes present
b)
Described in detail in
Interpretation/Result section
4) Other
a)
No abnormality found but findings
indicate some increased risk
b)
Example: presence of normal cells in a
postmenopausal woman may indicate
abnormality of endometrium
c)
Findings are described in
Interpretation/Result section
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Cytology Report, cont.
•
Interpretation/Result
– Detailed description of findings
1) Any significant benign changes (e.g.,
vaginal infections)
2) Any abnormal changes in cells
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Pap Test Results
HPV: human papillomavirus
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Cytology Report, cont.
•
Automated Review
– Indicates if specimen was evaluated using
an automated cytology computer imaging
device
– Name of device and results are specified
•
Ancillary Testing
– Any additional test methods (and results)
used to evaluate specimen
– Example: Human papilloma virus (HPV) test
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Cytology Report
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Bimanual Pelvic Examination
1. Physician performs after Pap test
2. Index and middle fingers of lubricated
gloved hand inserted into vagina
3. Fingers of other hand placed on patient's
lower abdomen
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Bimanual Pelvic Examination, cont.
4. Between the two hands:
a. Physician palpates uterus and ovaries for:
•
Size
•
Shape
•
Position
•
Detection of tenderness or lumps
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Bimanual Pelvic Examination
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Rectal-Vaginal Examination
1. Physician inserts gloved finger into
vagina and another gloved finger into
rectum
2. Physician obtains information on:
a. Tone and alignment of pelvic organs and
adnexal region (ovaries, fallopian tubes,
and ligaments of uterus)
b. Presence of hemorrhoids, fistulas, fissures
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Rectal-Vaginal Examination, cont.
3. Fecal material may be collected to test
for occult blood in stool
a. Purpose: early detection of colorectal
cancer
b. Typically performed on woman beginning at
age 40
c. Test used: Guaiac slide test (e.g.,
Hemoccult)
d. MA assists with collection and tests
specimen
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Vaginal Infections
1. Vagina: warm, moist environment that
encourages growth of microorganisms
a. Can result in vaginal infection (vaginitis)
2. If unusual vaginal discharge present:
a. Specimen collected to identify invading
organism
•
Evaluated at office or sent to laboratory
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Vaginal Infections, cont.
3. MA responsible for:
a. Assembling supplies
b. Labeling specimens
c. Completing laboratory request (if sent to
outside laboratory)
4. While assisting with collection:
a. Protect self from infection with pathogens
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Trichomoniasis
1. Trichomonas vaginalis: causative agent
of trichomoniasis (trich)
a. Pear-shaped protozoan with flagella: allows
for motility of organism
Modified from Mahon C, Manuselis G: Textbook of diagnostic microbiology, ed 2, Philadelphia, 2000, Saunders
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Trichomoniasis, cont.
2. Usually (but not always) spread through
intercourse
3. Symptoms
a. Profuse, frothy vaginal discharge
•
Yellowish-green
•
Unpleasant odor
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Trichomoniasis, cont.
b. Itching and irritation of vulva and vagina
c. Dyspareunia and dysuria
d. Cervix may exhibit small red spots
(strawberry cervix)
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Trichomoniasis, cont.
4. Identification
a. Wet preparation at medical office
•
Discharge placed on slide using sterile swab
•
Isotonic saline added
•
Coverslip placed over slide to protect it
Modified from Mahon C, Manuselis G: Textbook of diagnostic microbiology, ed 2, Philadelphia, 2000, Saunders
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Trichomoniasis, cont.
•
Physician examines slide
under microscope for
trich
– Observes for motility
of organism
Modified from Mahon C, Manuselis G: Textbook of diagnostic
microbiology, ed 2, Philadelphia, 2000, Saunders
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Trichomoniasis, cont.
b. Identification at an outside laboratory
•
Specimen placed in a transport medium
•
Must be transported to laboratory within 24
hours
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Trichomoniasis, cont.
5. Treatment: metronidazole (Flagyl)
a. Both the woman and sexual partner must be
treated
•
Prevents reinfection
•
Partner may harbor organism without noticeable
symptoms
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Candidiasis
1. Candida albicans: yeastlike fungus
a. Normally found in the intestinal tract
b. Frequent contaminate of vagina
c. Usually does not cause infection
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Candidiasis, cont.
2. Conditions that precipitate candidal
infection (by producing changes in the
vagina)
a. Pregnancy
b. Diabetes
c. Prolonged antibiotic therapy
3. Commonly called yeast infection
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Candidiasis, cont.
4. Symptoms
a. White patches on mucous membrane of
vagina
b. Thick odorless, cottage-cheese–like
discharge
•
Extremely irritating: causes burning and intense
itching
c. Vulval irritation
d. Dysuria
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Candidiasis, cont.
5. Identification
a. Identification at office: by wet preparation
•
Discharge placed on slide
•
Drop of 10% solution of potassium hydroxide
(KOH) added to slide
– Dissolves debris: allows for better
visualization of specimen
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Candidiasis, cont.
•
Physician observes slide under microscope for
Candida
– Observes for presence of yeast buds,
spores, hyphae
Modified from Mahon C, Manuselis G: Textbook of diagnostic microbiology, ed 2, Philadelphia, 2000, Saunders
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Candidiasis, cont.
b. Sent to outside laboratory
•
Specimen placed in transport medium
– Prevents drying and death of organism
•
Sent to laboratory for evaluation
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Candidiasis, cont.
6. Treatment
a. Vaginal ointments or suppositories
•
miconazole (Monistat)
•
clotrimazole (Gyne-Lotrimin)
•
nystatin (Mycostatin)
b. Oral medication
•
fluconazole (Diflucan)
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Candidiasis, cont.
7. Infection has a tendency to recur
a. Instruct patient to contact office if
symptoms reappear
Modified from Mahon C, Manuselis G: Textbook of diagnostic microbiology, ed 2, Philadelphia, 2000, Saunders
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Chlamydia
1. Caused by bacterium: Chlamydia
trachomatis
2. Fastest spreading sexually transmitted
disease in United States
a. Occurs most in female adolescents and
young adults
3. Most women with chlamydia are
asymptomatic
a. May not seek medical care until serious
complications have occurred
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Chlamydia, cont.
4. First attacks cervix: resulting in
cervicitis
5. If symptoms are present:
a. Dysuria
b. Itching and irritation of genital area
c. Yellowish odorless vaginal discharge
•
Appears 1 to 3 weeks after exposure
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Chlamydia, cont.
6. If not treated: can cause pelvic
inflammatory disease (PID)
a. Symptoms of PID
•
Lower abdominal pain
•
Fever
•
Nausea and vomiting
•
Dyspareunia
•
Vaginal discharge
•
Bleeding between periods
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Chlamydia, cont.
b. Complications of PID
•
Chronic pelvic pain
•
Scarring of fallopian tubes
•
Ectopic pregnancy
•
Infertility
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Chlamydia, cont.
7. Chlamydia in men
a. Symptoms
•
Mild dysuria
•
Thin watery discharge from penis
b. Symptoms appear only early in day
•
Are so mild that they may be ignored
c. If not treated: can cause epididymitis
•
Can result in infertility
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Chlamydia, cont.
8. Treatment of chlamydia
a. azithromycin (Zithromax)
b. doxycycline
9. Patient's partner should be tested and
treated if necessary
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Chlamydia, cont.
10. Diagnosis
a. DNA-based detection test (DNA probe test)
•
Detects presence of genes of chlamydia
bacteria
b. Specimen collected using sterile swab
c. Taken from endocervical canal in females
and from urethra in males
d. Instruct male not to void 1 hour before test
•
Voiding washes specimen out of urethra
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Chlamydia, cont.
e. Specimen placed in tube and sent to
laboratory
•
Preserves specimen
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Gonorrhea
1. Caused by bacterium Neisseria
gonorrhoeae
a. Gram-negative diplococcus
2. Infection of genitourinary tract
a. Transmitted through sexual intercourse
3. Often occurs in association with
chlamydia
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Gonorrhea, cont.
4. Women may be asymptomatic
5. If symptoms occur:
a. Dysuria
b. Yellow vaginal discharge
•
Occurs 2 to 10 days after infection
•
Are so mild: may be ignored
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Gonorrhea, cont.
6. If not treated: can cause PID
a. Can lead to infertility
7. Gonorrhea in men
a. Men exhibit more symptoms than women
•
Dysuria
•
Whitish discharge from penis: may progresses
to thick creamy discharge
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Gonorrhea, cont.
•
Burning and pain during urination (often severe)
– Usually prompts patient to seek treatment
b. If not treated: may cause epididymitis
•
Could lead to infertility
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Gonorrhea, cont.
8. Treatment of gonorrhea
a. Has become resistant to antibiotics
typically used
b. Newer types have been developed:
•
Ceftriaxone: one dose injection
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Gonorrhea, cont.
9. Diagnosis
a. DNA-probe test: detects presence of genes
of gonorrhea bacteria
b. Before development of DNA-probe test:
culture test used
•
Not used as much: gonorrhea difficult to culture
– Requires:
1) Oxygen atmosphere
2) Specially enriched culture medium
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What Would You Not Do?
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PRENATAL CARE
Obstetrics
1. Supervision of women's health during:
a. Pregnancy
b. Childbirth
c. Puerperium
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Obstetrics
2. Prenatal: The care of the pregnant woman
before delivery of the infant
a. Series of visits for promotion of health of
mother and fetus through:
•
Prevention of disease
•
Early detection, diagnosis, and treatment of
problems common to pregnancy
– Anemia
– Urinary tract infection (UTI)
– Preeclampsia
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Obstetrics Terminology
1. Braxton Hicks contractions: Intermittent
and irregular painless contractions that occur
throughout pregnancy
a. Occur more frequently at end of pregnancy
b. May be mistaken for true labor pains
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Obstetrics Terminology, cont.
2. Dilation (of the cervix): The stretching of the
external os from an opening of a few millimeters to
an opening large enough to allow passage of an
infant (approximately 10 cm)
3. Effacement: The thinning and shortening of
cervical canal from normal length (1 to 2 cm) to no
canal at all
a. Occurs late in pregnancy or during labor
b. Purpose: Permits passage of infant into birth
canal (along with dilation)
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Obstetrics Terminology, cont.
4. Embryo: The child in utero from the time of
conception to the beginning of the first
trimester (the first 2 months of development)
5. Engagement: The entrance of the fetal head
or the presenting part into the pelvic inlet
6. Fetus: The child in utero, from the third month
after conception to birth
7. Fundus: The dome-shaped upper portion of
the uterus between the fallopian tubes
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Obstetrics Terminology, cont.
8. Gestation: The period of intrauterine
development from conception to birth
a. Average pregnancy: 280 days or 40 weeks
from date of conception
9. Gestational age: The age of the fetus
between conception and birth
10. Infant: A child from birth to 12 months of age
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Obstetrics Terminology, cont.
11. Multigravida: A woman who has been
pregnant more than once
12. Multipara: A woman who has completed two
or more pregnancies to the age of viability
a. Regardless of whether they ended in live
infants or stillbirths
13. Nullipara: A woman who has not carried a
pregnancy to the point of viability (20 weeks)
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Obstetrics Terminology, cont.
14. Position: The relation of the presenting part
of the fetus to the maternal pelvis
15. Postpartum: Occurring after childbirth
16. Preeclampsia: A major complication of
pregnancy (cause unknown)
a. Symptoms
•
Increasing hypertension
•
Albuminuria
•
Edema
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Obstetrics Terminology, cont.
b. If not treated: may develop into eclampsia
•
Could cause maternal convulsions and coma
c. Occurs between the 20th week of
pregnancy and the end of the first week
postpartum
17. Presentation: Part of fetus closest to cervix
and will be delivered first
a. Cephalic presentation: head is presenting
against cervix
b. Breech presentation: buttocks or feet are
presented first
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Obstetrics Terminology, cont.
18. Primigravida: A woman pregnant for the first
time
19. Primipara: A woman who has carried a
pregnancy to viability (20 weeks) for the first
time
a. Regardless of whether the infant was
stillborn or alive at birth
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Obstetrics Terminology, cont.
20. Puerperium: The period of time (usually 4 to
6 weeks) after delivery in which uterus and
body systems return to normal
21. Quickening: The first movements of the fetus
in utero as felt by the mother
a. Occurs between 16 to 20 weeks
22. Toxemia: A pathologic condition that includes
preeclampsia and eclampsia
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Obstetrics Terminology, cont.
23. Trimester: Three months or one third of the
gestational period
a. The 9 months of pregnancy divided into 3
trimesters: each consisting of 3 months
•
First trimester: conception to 3 months
•
Second trimester: 4 to 6 months
•
Third trimester: 7 to 9 months
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PRENATAL VISITS
Prenatal and postpartal care divided into
categories
1. First prenatal visit
2. Return prenatal visit
3. Six weeks’ postpartum visit
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First Prenatal Visit
1. Occurs after a woman misses second
menstrual period
a. If problems exist: patient is seen after first
missed period
2. Often stressful for patient
a. Regardless of whether or not pt is happy
about pregnancy
a. Helpful to relax and reassure patient
3. Requires more time than subsequent
visits
a. Allow sufficient time in schedule
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First Prenatal Visit, cont.
4. Components
a. Completion of prenatal record form
b. Initial prenatal examination: complete
physical examination
c. Prenatal patient education
d. Laboratory tests
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The Prenatal Record
1. Purpose
a. Provide information regarding past and
present health status of patient
b. Data base and flow sheet for subsequent
visits
c. Identification of high-risk patients
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The Prenatal Record, cont.
2. MA responsible for obtaining information
for prenatal record
a. Opportunity for MA to:
•
Develop rapport with patient
•
Relay information to patient
– Changes taking place in body
– Signs/symptoms of labor
– Nutrition of infant
– Care of newborn
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Past Medical History
3. Components of the Prenatal Record
a. Past Medical History
•
Conditions that could affect mother and fetus
(e.g., kidney disease, hypertension, sexually
transmitted diseases, diabetes, alcohol and
tobacco intake, drug addiction)
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Past Medical History
•
Immunizations and childhood diseases:
– To assess antibody protection against
diseases
– Rubella: if contracted during pregnancy can
be dangerous to fetus
– Patient who has no antibody protection to
rubella: given immunization within 6 weeks
of delivery
– Rubella cannot be given to pregnant
woman: harmful to fetus
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Menstrual History
b. Menstrual History
•
Date of onset of menstruation
•
Menstrual interval cycle
•
Duration
•
Amount of flow
•
Gynecologic disorders
•
Whether or not pt was using contraceptive when
became pregnant
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Prenatal Record
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Obstetric History
c. Obstetric History
•
Information on previous pregnancies
– Gravidity (G): Number of times patient has
been pregnant
1) Regardless of duration of pregnancy
2) Including the current pregnancy
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Obstetric History, cont.
3) Examples:
a) A woman pregnant for the first
time: G1
b) A woman pregnant for the second
time: G2
c) Multiple births (twins): count as
only one pregnancy
d) Example: Woman pregnant for the
second time with twins: G: 2
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Obstetric History, cont.
– Parity (P): The condition of having borne
offspring regardless of the outcome
1) Recorded using four digits representing the
following:
a)
Term birth (T): delivery after 37 weeks
whether alive or stillborn
o Multiple births count as one delivery
Preterm birth (P): delivery between 20 and
37 weeks whether alive or stillborn
b)
Abortion (A): termination of pregnancy
before fetus reached age of viability (20
weeks)
o Spontaneous or elective
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Obstetric History, cont.
d)
Living children (L): number of
living children
e)
Information to obtain if the woman
is a multigravida:
o Length of pregnancy
o Hours of labor
o Type of delivery (vaginal or cesarean)
o Type of anesthesia
o Sex and weight of newborn
o Maternal or infant complications
f)
Assists in identifying areas that
may need to be investigated or
monitored during prenatal period
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Present Pregnancy History
d. Present Pregnancy History
•
Establishes baseline for present health status of
patient
•
Identifies presence of any warning signs of
pregnancy:
– Persistent headaches
– Visual disturbances
– Abdominal pain
– Vaginal bleeding or discharge
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Present Pregnancy History, cont.
•
Patient asked if has had early signs of
pregnancy (e.g., nausea, vomiting, fatigue,
breast changes)
•
Prescription or over-the-counter (OTC) meds
(including vitamins and herbals)
– Instruct patient not to take any meds
without checking with physician (could be
harmful to fetus)
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Present Pregnancy History, cont.
•
Calculating expected date of delivery (EDD):
– Nagele's rule
1) Add 7 days to the first day of last
menstrual period
2) Subtract 3 months
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Present Pregnancy History, cont.
1) Add 1 year
a) Using this method:
o
Some 4% of patients deliver
spontaneously on EDD
o
Majority deliver 7 days
before or 7 days after EDD
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Present Pregnancy History, cont.
– Gestation calculators: line up arrow and
date of last menstrual period using:
1) Movable cardboard wheel (See Figure 812)
2) Requires less time
3) Provides information of probable size of
fetus on any given date
a) If patient is unsure of last
menstrual period: physician
estimates by other methods (e.g.,
fundal height measurement,
sonography)
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Gestation Calculator
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Prenatal Record
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Interval Prenatal History
e. Interval Prenatal History
•
Updates record during return visits
•
Data collected
– Weight
– Blood pressure (BP)
– Urine testing results
– Fundal height measurement
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Interval Prenatal History, cont.
– Fetal heart rate
– Additional signs of pregnancy
– How patient is feeling
– Concerns or symptoms
1) Assists in planning, implementing, and
evaluating individual needs of patient
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Interval Prenatal History
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Initial Prenatal Examination
1. Purpose
a. Confirm the pregnancy
b. Establish baseline for woman's state of
health
c. Identify high-risk prenatal patients
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Initial Prenatal Examination, cont.
2. Includes:
a. Gynecologic examination
•
Breast and pelvic examinations
b. General physical examination: diagnosis of
conditions that could cause complications
(obesity, hypertension, severe varicosities,
uterine size inappropriate for due date)
•
Treatment or monitoring are instituted to
prevent complications
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Initial Prenatal Examination, cont.
3. Preparation of the Patient
a. Measurement of:
•
Vital signs
•
Height and Weight
-Provides data base
for subsequent visits
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Initial Prenatal Examination, cont.
b. Instruct patient to disrobe completely
•
Put on examine gown: opening in front
c. Ask patient if she needs to void
•
Empty bladder:
– Facilitates examination
– More comfortable for patient
•
Urine specimen may be required
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Initial Prenatal Examination, cont.
d. Assist patient on and off
the scale and examining
table: ensures safety and
comfort
•
Pull out footrest
•
Support patient on and off
table
– Especially important as
pregnancy progresses:
patient becomes more
awkward and offbalance
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Initial Prenatal Examination, cont.
e. Set up tray for examination
f. Position patient as needed for examination
g. Assist physician as necessary
h. See Table 8-2 for procedures included in
prenatal examination
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Initial Prenatal Examination, cont.
4. Patient Education
a. Instructions given to patient on:
• Diet
• Weight gain
• Rest
• Sleep
• Clothing
• Employment
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Initial Prenatal Examination, cont.
•
•
•
•
Exercise
Travel
Intercourse
Bowel
function
• Dental care
• Smoking and
alcohol
• Drugs
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Initial Prenatal Examination, cont.
b. Prenatal guidebook usually given to patient
c. Teaching films may be available for viewing
by patient
d. Patient prescribed a daily vitamin
supplement
•
Ensures mother and fetus obtain adequate
vitamins/minerals
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Initial Prenatal Examination, cont.
e. MA responsible for:
•
Scheduling return visits
•
Making sure patient understands instructions
f. Instruct patient:
•
To report any warning signs
•
Not to take meds without checking with
physician
•
Contact medical office with questions
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Prenatal Laboratory Tests
5. Laboratory tests
a. Purpose
•
Assist in assessment of patient's state of health
•
Detect problems
b. Important for physician to have results by
next office visit
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Prenatal Laboratory Tests, cont.
c. Prenatal blood tests: require venipuncture
•
Collected at medical office or outside laboratory
d. Based on results of prenatal examination
and laboratory tests:
•
Additional tests may be ordered to assess
patient's condition
e. Some tests scheduled later in the
pregnancy (glucose challenge, group B
streptococci)
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Urine Tests
f. Urine Tests
•
Complete urinalysis: physical, chemical, and
microscopic analysis
– Clean-catch midstream specimen required
•
If bacteria present: culture and sensitivity
ordered
– To determine if urinary tract infection is
present
•
Urine pregnancy test may be performed
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Pap Test
g. Swab Tests
•
Pap Test
– Detection of abnormal cell growth
– Diagnosis of precancerous and cancerous
conditions
– Hormonal assessment (MI)
– Detection of vaginal infections
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Chlamydia
•
Chlamydia: can be passed from woman to baby
during childbirth
– Can result in conjunctivitis and pneumonia
in newborn
– Patient treated with antibiotics
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Gonorrhea
•
Gonorrhea: could infect infant's eyes during
passage through birth canal
– Results in ophthalmia neonatorum
– If not treated: can lead to blindness
– Most states require
1) Pregnant women be tested for gonorrhea
2) Eyes of newborn be treated with antibiotic
or silver nitrate drops immediately after
birth:
(a) Kills gonococcal bacteria if present
– Patient treated immediately with antibiotics
1) To prevent problems
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Trichomoniasis and Candidiasis
•
Trichomoniasis and Candidiasis
– Presence of excessive vaginal discharge:
physician tests for trich and candidiasis
– Candidiasis: must be treated before delivery
to prevent thrush in newborn (yeastlike
infection of infant's mucous membrane of
mouth or throat)
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Group B Streptococcus
•
Group B Streptococcus (GBS)
– Common bacteria often found in vagina and
rectum of healthy adult woman
1) 1 out of 4 pregnant women carries GBS
– Not harmful to pregnant women
– Can cause life-threatening infections in
newborn
– Newborn becomes infected during passage
through birth canal
1) May develop septicemia (infection of
blood), pneumonia, or meningitis
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Group B Streptococcus, cont.
– Prevention: patient tested for GBS at 35 to
37 weeks of pregnancy
– Collection of specimen
1) Two swabs: specimens collected from
vagina and rectum
2) Placed in transport tube and sent to
laboratory
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Group B Streptococcus, cont.
– Presence of GBS
1) Patient is treated with IV antibiotics
every 4 hours during labor until delivery
2) In most cases: prevents newborn from
becoming infected
– If newborn infected with GBS: antibiotics
administered immediately and baby closely
monitored
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Complete Blood Count (CBC)
– Blood Tests
1) Complete blood count (CBC)
a) Screening test: assesses patient's
state of health
b) Includes:
–
Hemoglobin
–
Hematocrit
–
White blood cell (WBC) count
–
Differential white cell count
–
Platelet count
–
Red blood cell indices
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Hemoglobin and Hematocrit
1) Hemoglobin and Hematocrit
a) Low values: anemia
b) Prenatal patients have
tendency to develop anemia
–
Due to increased demand
for red blood cells
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Hemoglobin and Hematocrit, cont.
c)
d)
Treatment:
–
Iron supplements
–
Nutritional counseling
Checked again at 32 weeks of
gestation
–
Precaution against anemia
before delivery
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Rh Factor and ABO Blood Type
1)
Rh Factor and ABO Blood Type
a) Purpose: to anticipate ABO and Rh
incompatibilities
b) If mother is Rh-negative: father
must be tested
–
If father Rh-positive: Rh
incompatibility may exist
–
Rh antibody titer test is
performed throughout
pregnancy
o To determine if mother's
antibody level is increasing
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Increased Rh Antibody Level
c)
Increased Rh antibody level: could
be dangerous to fetus
–
Could result in:
o Severe anemia
o Jaundice
o Brain damage
o Heart failure
o Sometimes death of fetus
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Glucose Challenge Test (GCT)
1) Glucose Challenge Test (GCT)
a) Performed between 24 and 28
weeks
b) Screens for gestational
diabetes mellitus (GDM)
c) Assesses body's response to a
measured glucose solution
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Glucose Challenge Test (GCT),
cont.
d)
No fasting required
e)
Patient drinks 50 grams of a
glucose solution
–
f)
Glucose measured 1 hour
later
Results
–
Less than 140mg/dL: negative
for GDM
–
Greater than 140 mg/dL:
o 3-hour glucose tolerance
test must be performed
before GDM diagnosis
can be made
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Syphilis Test
5) Serology Test for Syphilis
a) Treponema pallidum
(microorganisms that cause
syphilis) can cross placenta and
infect fetus; could cause:
–
Intrauterine death
–
Fetus to be born with
congenital syphilis
b) Congenital syphilis: child born with
deformities
–
May become blind, deaf,
paralyzed, insane
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Syphilis Test, cont.
c)
Screening tests for syphilis
–
VDRL (Venereal Disease
Research Laboratory)
–
RPR (rapid plasma regain)
o Results reported as
nonreactive, weakly
reactive, or reactive
o Positive test requires
more specific test to
arrive at a diagnosis
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Rubella Antibody Titer
6) Rubella Antibody Titer
a) Assesses level of antibody against
rubella (German measles)
b) Determines whether woman is
immune to rubella
c) Rubella contracted during
pregnancy: can cause serious
congenital abnormalities in fetus
d) Patients who lack immunity:
immunized within 6 weeks after
delivery
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Rh Antibody Titer
7) Rh Antibody Titer (on Rh-Negative Blood
Specimens)
a)
Detects amount of circulating Rh
antibodies against red blood cells
b)
Can occur in Rh-negative woman
carrying Rh-positive fetus
c)
Titer performed on women who are Rhnegative
d)
Titer levels assessed during the
pregnancy
–
e)
Determines if antibody level is
increasing
Increased Rh antibody level: dangerous
to fetus
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Rh Antibody Titer, cont.
f)
Preventive measure for Rh-negative
women with potential of having Rhpositive baby (who test negative for Rh
antibodies):
–
Administration of two injections
of Rh immune globulin (RhoGAM)
o
Prevents formation of Rh
antibodies in mother (avoids
Rh incompatibility
complications during next
pregnancy)
o
First injection: administered
at 28 weeks and second
given within 72 hours of
delivery
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Hepatitis B and HIV
8) Hepatitis B and HIV
a) CDC recommends screening test
for hepatitis B
–
Test: HBsAg
b) Mother with hepatitis B has
increased risk of:
–
Spontaneous abortion
–
Preterm labor
–
Transmitting hepatitis to infant
during delivery
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Hepatitis B and HIV, cont.
c)
For women who test positive
–
Risk of baby contracting
hepatitis greatly reduced by
administering to newborn:
o Hepatitis B immune
globulin (HBIG)
o Hepatitis B vaccine
–
Administered to baby within
12 hours of birth
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Hepatitis B and HIV, cont.
d)
CDC recommends testing for HIV
be offered to pregnant woman
–
Babies born to women who
are HIV positive:
o At risk for developing HIV
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LABORATORY TEST REPORT
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193
What Would You Do?
What Would You Not Do?
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194
What Would You Do?
What Would You Not Do?
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195
Return Prenatal Visits
1. Continuous assessment of health of
mother and fetus
2. During each visit:
a. Data collected and recorded in prenatal
record
b. If signs of pathologic condition present:
•
Physician performs examination to diagnosis
and treat condition
•
Diagnostic/laboratory tests may also be ordered
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Return Prenatal Visits, cont.
3. Schedule of prenatal visits
a. Every 4 weeks for first 28
weeks
b. Every 2 weeks until 36
weeks
c. Weekly thereafter until
delivery
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Return Prenatal Visits, cont.
4. Also provides opportunity to:
a. Lend support to mother
b. Provide prenatal education
c. Ensure mother is well-informed and
prepared during pregnancy, childbirth, and
postpartum period
d. Answer patient questions
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Return Prenatal Visits, cont.
5. Urine specimen
a. Patient obtains urine specimen during each
return visit
b. Specimen tested for glucose and protein
•
Positive glucose: may indicate GDM or a
prediabetic condition
•
Positive protein: may indicate UTI or
preeclampsia
c. Further testing: to arrive at a final
diagnosis
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Return Prenatal Visits, cont.
6. Procedures performed by physician
a. Measurement of fundal height
b. Measurement of the fetal heart rate
c. Vaginal examination
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Fundal Height Measurement
7. Fundal Height Measurement
a. Pregnant uterus rises gradually into
abdominal cavity
b. Fundus is palpable between 8th and 13th
weeks of pregnancy
c. First measurement performed at first visit
•
Used as guideline for all subsequent
measurements
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Fundal Height Measurement, cont.
d. Physician places one end of a cm tape
measure on the superior aspect of
symphysis pubis and measures to top of
uterine fundus
•
Results recorded on a flow chart
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Fundal Height Measurement, cont.
e. Purpose
•
Rough estimate of duration of pregnancy during
1st and second trimesters
•
Assess whether fetal development is
progressing normally
– Growth too rapid or too slow: further
evaluated
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Fundal Height Measurement, cont.
– May indicate:
1) Multiple pregnancies
2) Polyhydramnios
3) Ovarian tumor
4) Intrauterine growth retardation (IUGR)
5) Intrauterine death
6) Error in estimating fetal progress
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Fundal Height Measurement
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Fetal Heart Tones
8. Fetal Heart Tones (FHT)
a. Normal fetal heart rate (FHR): 120 to 160
bpm
b. Slow or rapid heartbeat: usually indicates
fetal distress
c. FHT: heartbeat of fetus as heard through
mother's abdominal wall
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Fetal Heart Tones, cont.
d. Doppler fetal pulse detector
•
Detects FHT between 10th and 12th weeks of
gestation
•
Converts ultrasonic waves into audible sounds
of fetal pulse
•
Consists of main control unit and a probe
•
Probe head contains transducer: generates
sound waves
– Delicate: do not drop to prevent damaging it
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Fetal Pulse Detector
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Fetal Heart Tones, cont.
•
Ultrasonic coupling agent
spread on abdomen
– Increases conductivity
of sound waves
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Fetal Heart Tones, cont.
•
Probe head placed in gel and moved until fetal
heart tones are located
– Broadcast through a loudspeaker in main
unit
– FHT: sound like hoofbeats of galloping horse
– LCD screen: provides digital display of pulse
rate
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Fetal Heart Tones
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Fetal Heart Tones, cont.
•
Headphones: for private listening
•
Remove gel with paper towel
•
Clean probe head with damp cloth or paper
towel
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Vaginal Examination
9. Vaginal Examination
a. May be performed at any time during
pregnancy
•
In normal pregnancy: usually no need to perform
until patient nears term
– Usually performed 2 to 3 weeks from EDD
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Vaginal Examination, cont.
b. Purpose
•
Confirm the presenting part
•
Determine degree (if any) of cervical dilation
and effacement (see Figure 8-16)
– Purpose of dilation and effacement: Permits
passage of infant from uterus into birth
canal
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Special Tests and Procedures
1. Triple Screen Test
a. Performed between 15th and 20th weeks
b. Used to screen for:
•
Neural tube defects
•
Down syndrome
•
Trisomy 18
•
Ventral wall defects
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Triple Screen Test
c. Not a mandatory test
•
Has high incidence of false-positive results
d. Abnormal results: further testing required
to determine if abnormality exists
(ultrasound, amniocentesis)
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Obstetric Ultrasound Scan
2. Obstetric Ultrasound Scan
a. Used to view fetus in utero
•
Continuous viewing of fetus
•
Shows fetal movement
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Obstetric Ultrasound Scan, cont.
b. Purpose
•
Evaluates health of fetus
•
Determines gestational age
– By taking various measurements of fetus
(e.g., crown-rump length)
c. Uses high-frequency sound waves to
produce an image (sonogram)
d. Image is displayed on monitor
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Obstetric Ultrasound Scan, cont.
e. Two methods of performing scan:
•
Transabdominal Ultrasound Scan
– Used most often
– Patient must have full bladder: provides
clear visualization of uterus
1) Patient consumes 32 ounces of water: 1
hour before scan
– Patient placed in supine position
– Draped with abdomen exposed
– Coupling agent applied: increases
transmission of sound waves
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Obstetric Ultrasound Scan, cont.
– Probe placed in gel and moved slowly
– Image of fetus displayed on screen
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Obstetric Ultrasound Scan, cont.
•
Endovaginal Ultrasound Scan
– Performed in early stages of pregnancy (up
to 12 weeks)
– Empty bladder: makes examination more
comfortable
– Patient placed in lithotomy position
– Vaginal probe placed into vagina
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Obstetric Ultrasound Scan, cont.
– Provides a clear image at beginning of
pregnancy
1) Because probe close to uterus
– Image of embryo displayed on screen
– Can be performed anytime during
pregnancy
1) Usually performed:
a) Between 7 to 12 weeks
b) 18 to 20 weeks
c) Sometimes at 34 weeks
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Amniocentesis
3. Amniocentesis
a. Performed between 15th and 18th weeks
b. Aids in prenatal diagnosis of:
•
Certain genetically transmitted errors of
metabolism
•
Congenital abnormalities
•
Chromosomal disorders (e.g., Down syndrome)
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Amniocentesis, cont.
c. Also used to:
•
Detect fetal jeopardy or distress
•
Assess fetal lung maturity (later in pregnancy)
•
Determine if baby is boy or girl
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Amniocentesis, cont.
d. Procedure
•
Long, thin needle inserted through abdomen
into amniotic sac surrounding fetus
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Amniocentesis, cont.
– Obstetric ultrasound scan performed in
conjunction with amniocentesis (so
physician knows where to insert needle)
•
Sample of fluid withdrawn
– Sent to laboratory: usually takes 1 to 3
weeks for results
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Amniocentesis, cont.
e. Slight risk of:
•
Bleeding
•
Leakage of fluid
•
Infection of amniotic fluid
•
Miscarriage
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Amniocentesis, cont.
f. Offered only to women at high risk for fetal
abnormalities
•
35 or older
•
Have a child with a genetic or neural tube defect
•
Abnormal triple screen test results
•
If a parent has a chromosomal abnormality or is
a carrier of a metabolic disease
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Fetal Heart Rate Monitoring
4. Fetal Heart Rate (FHR) Monitoring
a. Performed to obtain information on physical
condition of fetus
b. Conditions that warrant procedure
•
Fetal growth that is not progressing well
•
Decreased amniotic fluid
•
Decreased fetal activity
•
Elevated blood pressure
•
GDM
•
Overdue baby
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Fetal Heart Rate Monitoring, cont.
c. To perform procedure:
•
Electronic microphone strapped to abdomen:
– Amplifies fetal heartbeat
•
Gel applied under microphone: makes sounds
clearer
•
FHR is:
– Heard
– Displayed on a screen
– Printed on special paper
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Fetal Heart Rate Monitoring, cont.
d. FHR monitoring procedures
•
Nonstress test (NST)
– Monitors changes in heart rate in response
to fetal movements
– Mother pushes button when feels baby move
– Normal: baby's heart rate increases with
movement
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Fetal Heart Rate Monitoring, cont.
– Instruct mother to eat a light meal within 2
hours of procedure
1) Stimulates fetal movement
– Abnormal test results: contraction stress
test ordered
•
Contraction stress test (CST)
– Similar to NST
– Mild contractions of uterus are stimulated
for a short time
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Fetal Heart Rate Monitoring, cont.
– Used to evaluate response of baby's heart
rate to contractions
1) Determines if baby can withstand stress
of labor
– Abnormal results: further tests are required
to:
1) Evaluate well-being of baby
2) Decide how and when to deliver baby
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Medical Assisting Responsibilities
1. Assemble equipment and supplies
2. Obtain information to update prenatal
record
3. Prepare patient for examination
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Medical Assisting Responsibilities,
cont.
4. Assist physician during examination
5. Perform urine testing
6. Measure BP and weight
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235
What Would You Do?
What Would You Not Do?
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236
What Would You Do?
What Would You Not Do?
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Six-Week Postpartum Visit
1. Puerperium: period of time when body
systems return to prepregnant state
a. Usually extends for 4 to 6 weeks after
delivery
b. Changes take place in body
•
Involution of uterus: uterus returns to normal
size
•
Healing of any injuries sustained to birth canal
during delivery
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Six-Week Postpartum Visit, cont.
2. Lochia: discharge from the uterus after
delivery
a. Consists of:
•
Blood
•
Tissue
•
White blood cells
•
Mucus
•
Some bacteria
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Six-Week Postpartum Visit, cont.
b. Color of lochia: indication of progress of
uterine healing
•
Lochia rubra: lochia consisting of blood
– Occurs during first 3 days
•
Lochia serosa: lochia becomes pink or
brownish; amount of blood decreases
– Occurs fourth day after delivery
•
Lochia alba: lochia flow decreases and becomes
yellowish-white
– Occurs by 10th day after delivery
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Six-Week Postpartum Visit, cont.
c. Lochia keeps decreasing; becomes pale in
color
d. Usually disappears by third week (not
unusual for discharge to last 6 weeks)
e. Patient should contact office if:
•
Discharge increases instead of decreases
•
Discharge is absent in first 2 weeks after
delivery
•
Discharge changes to red after being yellowishwhite
•
Foul odor is present
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Six-Week Postpartum Visit, cont.
3. Menstruation begins:
a. About 2 months after delivery in nonnursing
mother
b. 3 to 6 months in nursing mother
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Six-Week Postpartum Visit, cont.
4. Instruct patient to:
a. Avoid fatigue
b. Avoid heavy lifting
c. Consume nutritious well-balanced diet
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Six-Week Postpartum Visit, cont.
5. Purpose of 6-week visit
a. Evaluate general physical condition of
patient
b. Make sure there are no residual problems
from childbearing
c. Provide patient with education
•
Methods of contraception
•
Infant care
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Six-Week Postpartum Visit, cont.
6. Patient is asked about problems related
to:
a. Vaginal discharge
b. Urinary or bowel function
c. Breastfeeding (if nursing)
7. MA instructs patient:
a. BSE procedure
b. Importance of annual Pap test
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Six-Week Postpartum Visit, cont.
8. Physician performs following:
a. Evaluates general physical condition of patient
b. Perform breast and pelvic exams
c. Determine if muscle tone has returned to
abdominal wall
d. If patient does not have protection against
rubella:
•
Rubella immunization is administered
e. Hemoglobin and hematocrit usually performed
•
Screen for anemia due to blood loss during delivery
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Six-Week Postpartum Visit, cont.
9. MA responsible for:
a. Measuring and recording vital signs
b. Measuring and recording weight
c. Preparing patient for examination
•
Patient must disrobe completely
– Put on examining gown with opening in front
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Six-Week Postpartum Visit
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POSTTEST
True or False
1.
The patient position for a breast examination is the
lithotomy position.
2.
Most breast lumps are discovered by the physician.
3.
Trichomoniasis is caused by a virus.
4.
Chlamydia often occurs in association with syphilis.
5.
In the absence of complications, the first prenatal
visit should be scheduled after a woman misses her
first period.
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POSTTEST, CONT.
True or False
6.
True labor pains are referred to as Braxton Hicks
contractions.
7.
The purpose of measuring fundal height is to
determine the degree of cervical dilation and
effacement.
8.
The fetal heart tones can first be detected between 4
and 6 weeks of gestation using a Doppler fetal pulse
detector.
9.
The mother must fast for 12 hours before having an
obstetric ultrasound scan.
10. The perineum is the period of time in which the body
systems are returning to their prepregnant state.
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