Evelyn M. Hickson, RN, MSN, CNS, WCC
Identify potential complications of pregnancy based on prenatal history, physical assessment and lab values.
Discuss the role of the perinatal nurse in screening, identifying, documenting and referring patients with history of domestic violence or substance use during pregnancy.
Discuss maternal infections, modes of treatment, and potential impact on the infant.
Review office reports, including
Personal medical history
Note any areas of concern identified by the care provider
Blood type and antibody screen
Glucose tolerance testing
How early did she start prenatal care?
Preterm (<37 wk) births
Abortions (elective, therapeutic or spontaneous)
Length of previous labors, infant birth weight, gestational age at delivery
History of preterm labor or delivery
Previous operative delivery
History of postpartum hemorrhage or postpartum depression
Marital status or available family support
CPS or other alerts
Referral to social services
Religious or cultural practices
Sometimes the urgency of the situation dictates the order in which one proceeds with a patient interview, such as:
Unstable maternal condition
(Unconscious, bleeding, seizing, etc)
Category 3 fetal tracing
Note the date and time of patient arrival
Is your baby moving?
Are you contracting? If so, when did they start and how often are they occurring?
Are you experiencing vaginal bleeding, discharge, or leaking of fluid?
Are you in pain? Orient the patient to the pain scale and discuss her plans for pain management.
Send them to bathroom for UA.
Dose, route, last taken
Allergies and reactions
When the patient last ate or drank
(including what was eaten or drunk)
Complications with current or previous pregnancy
Nausea or vomiting
Frequency or burning with urination
Orient patient to monitors and basic strip interpretation
Vital signs (full set)
Physical exam including:
DTRs and Clonus
Breath sounds if patient presents with respiratory symptoms
Time contractions started
Frequency, duration, and regularity of contractions
Palpation of maternal abdomen during and between contractions
Pain assessment, including location and type of pain
Castor bean or castor oil
Cinnamon (spice tea)
Red raspberry leaf tea
Intercourse in last 12-24 hours
Time possible SROM occurred
Color, amount, and smell of fluid
Testing of vaginal discharge for presence of amniotic fluid
Warning signs of drug abuse:
Noncompliance with prenatal care
– late entry or no prenatal care
–due to adolescence, obesity, low socioeconomic status
Current or previous history of encounters with law enforcement
Marital & family disputes
Intrapartum signs of substance abuse
3 rd trimester stillbirth
Unexpected preterm birth
Placental abruption in a woman without hypertensive disorders.
Social service consult, CPS, drug treatment
Majority of abused women continue to be victimized during pregnancy and may escalate.
Most estimate rates between 4
Child abuse occurs in 33
– 77% of families with adult abuse.
No single profile of an abused woman: all racial, economic, educational, religious, ethnic and social backgrounds.
Signs of domestic violence in the pregnant patient include:
unwanted pregnancy late entry into prenatal care
missed appointments substance abuse or use poor weight gain and nutrition multiple, repeated somatic complaints.
Should be conducted in private, with
only the patient
“Because violence against women is so common, I ask all of my patients do you have any reason to feel unsafe at home?”
Document patient statements accurately and quote them directly
Acute abdominal pain
Temperature of 100.4 F or higher
Preterm rupture of membranes
Non-reassuring fetal heart rate pattern
Best method to speak to providers
Gives you a standard list of things you need to be prepared to discuss with them
Be concise and factual
Do not use “touchy-feely” language
What is going on with the patient?
What is the clinical context?
What do I think the problem is?
What would I do to correct it?
Prior to calling the provider:
Have I assessed the patient myself?
Has the situation been discussed with a resource nurse or preceptor?
Have the following available when speaking:
List of current medications, allergies, whether IV was placed and labs drawn
Most recent vital signs
Reporting lab results: provide the date and time test was done and results of previous labs for comparison
What is the situation you are calling about?
Identify self, unit, patient, room number
State who the patient’s doctor has been for the pregnancy
Briefly state the problem, what is it, when it happened or started, and how severe.
Pertinent background information related to the situation could include:
Gestation, GTPAL, age, previously identified risk factors
List of current medications, allergies, labs
Most recent vital signs
What is your assessment of the situation?
What is your recommendation or expectation?
Admission for labor
Patient needs to be seen
Patient needs antibiotics for UTI, etc.
Document the care provider notification, orders received, changes in patient condition, and plan.
Guidelines for Communication with
Physicians Using SBAR
Use the following according to provider preference.
During weekdays, the office directly
On weekends and after hours during the week, home phone
Wait no longer than
For emergent situations, use the appropriate chain of command as needed to ensure safe patient care.
Guidelines for Perinatal Care, (6 th ed.)/AAP and
Lowdermilk, D. and Perry, S. (2007). Maternity and Women’s Health Care (9th ed.). St. Louis,
MI: Mosby Elsevier.
Mattson, S. and Smith, J. (2004). Core
Curriculum for Maternal-Newborn Nursing (3rd ed.). St. Louis, MI: Mosby Elsevier.
Simpson, K. and Creehan, P. (2010). Perinatal
Nursing (3rd ed.). Philadelphia, PA: Lippincott.