Case Study SAMPLE
You are seeing a 28-year-old African American female, G6 P 3115, who is currently on oral combined hormonal contraception. She’s 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 haven’t been using any contraception since then. Upon questioning, she states that on the Pill, sometimes her menstrual periods are very light and once she didn’t 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.
Estimated Date of Delivery (EDD)
It will be difficult to establish an estimated date of delivery for the patient in case study 2. She reports that she discontinued her birth control medication 3 months ago but has not had a menstrual period for about 5 months. Her periods have been very light on the oral contraceptives and she has had a history of missing a period on the pills. The patient could be anywhere from 9 weeks (when she stopped oral contraceptives) to 22 weeks (if oral contraceptives were taken incorrectly or did not work) pregnant based on Nӓgelé’s Rule (Schuiling & Likis, 2017). Based on her history, the best way to date her pregnancy would be to obtain an ultrasound. Ultrasound measurement of the fetus in the first 13 6/7 weeks is the most accurate method to establish or confirm gestational age (The American College of Obstetricians and Gynecologists [ACOG], 2017). If she is in the second trimester when the initial ultrasound is performed, regression formulas which incorporate biparietal diameter and head circumference, femur length, and abdominal circumference can be used to increase dating accuracy (ACOG, 2017). Her EDD may be inaccurate by 7-14 days if she is in the second trimester of pregnancy (ACOG, 2017).
Recommended Procedures and Screenings
During the patient’s initial visit, a urine pregnancy test and ultrasound examination should be performed to help establish the estimated due date (ACOG, 2017). A thorough patient history and physical examination will also need to be completed so that the woman’s risk for complications can be identified (Schuiling & Likis, 2017). The history should include the woman’s medical, surgical, medication, obstetric, gynecologic, menstrual, family, social, and occupational history, as well as, questioning the patient if she has enough social support and necessary resources to support her pregnancy (Schuiling & Likis, 2017). Initial screening tests will vary based on the patient’s established EDD. She should have the following labs drawn at her initial visit: complete blood count (CBC), blood type, Rh factor, antibody screen, rubella titer, hepatitis B surface antigen, human immunodeficiency virus, Syphilis testing, urine culture, chlamydia and gonorrhea testing, and others based on her history (screening for diabetes, varicella antibody, hepatitis C, thyroid-stimulating hormone, Pap smear, and genetic screening [if she is within the window]) (Schuiling & Likis, 2017).
Missed Procedures or Screenings
Women should be encouraged to implement prenatal care as soon as they know that they are pregnant so that important procedures and screenings can be instituted in a timely manner. Routine prenatal procedures and screenings exist to keep mother and baby as healthy as possible. When initiated early in the pregnancy, screenings can reduce the risk for complications for both mother and baby. Complications can include preterm labor, intrauterine growth retardation, perinatal depression, preeclampsia, gestational diabetes, neurodevelopmental delay, miscarriage, low birth weight, and premature rupture of membranes among others (Zolotor & Carlough, 2014).
Plan of Care
The purpose of prenatal care is to provide preventative health care to pregnant women and to promote optimal pregnancy and birth outcomes (Tharpe, Farley, & Jordan, 2017). At the initial visit, the pregnant woman should receive a prescription for prenatal vitamins, proof of pregnancy, an order for lab work, an order for ultrasound, information about prenatal care, and additional resources based on the initial assessment (Schuiling & Likis, 2017). It is important to determine if the woman is safe, has adequate food and housing, and has health insurance (Schuiling & Likis, 2017). Cessation of unhealthy behaviors should be stressed: tobacco use, alcohol use, drug abuse, and caffeine intake. The patient should be instructed on the appropriate amount of weight gain that she should have based on her baseline body mass index (Schuiling & Likis, 2017). She should be encouraged to engage in a healthy lifestyle with mild to moderate exercise, adequate rest, stress management, and a well-balanced diet (Tharpe, Farley, & Jordan, 2017). She should be instructed to avoid illness and toxic environmental exposures (such as lead, cigarette smoke, mercury, and organic solvents) (Schuiling & Likis, 2017). She should be taught about what to expect with her prenatal visits and her birth plan should be discussed (Tharpe, Farley, & Jordan, 2017). She should be taught about common discomforts that may occur during pregnancy and warning signs that warrant immediate attention (such as severe abdominal pain and heavy bleeding) (Schuiling & Likis, 2017; Tharpe, Farley, & Jordan, 2017). The patient should receive information about parenting classes, childbirth classes, and centering groups that are available to her (Tharpe, Farley, & Jordan, 2017). The patient should be given the contact information for her provider and encouraged to contact her provider with any questions or concerns.
References
The American College of Obstetricians and Gynecologists. (2017). Committee Opinion Number 700: Methods for Estimating the Due Date. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Methods-for-Estimating-the-Due-Date.
Schuiling, K. D. & Likis, F. E. (2017). Women’s Gynecologic Health (3rd ed.). Burlington, MA: Jones & Bartlett Publishers.
Tharpe, N. L., Farley, C. L., & Jordan, R. G. (2017). Clinical Practice Guidelines for Midwifery & Women’s Health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.
Zolotor, A. J. & Carlough, M. C. (2014). Update on Prenatal Care. American Family Physician, 89(3), 199-208. Retrieved from https://www.aafp.org/afp/2014/0201/p199.html.