Dating a Pregnancy, GTPAL System, and Trimesters (Nursing)

00:00 So, we talked about signs and symptoms of pregnancy, now let's get to sort of the meat.

00:07 When I have had pregnant patients come into my office, one of the first questions they ask is "When is my baby coming? How far along am I?" That's a really important question and we have several ways we can answer that. The first way is that we can use a patient's last menstrual period. What's really important when you asks someone when their last menstrual period was is to confirm that we're talking about the very first day. Sometimes, patients like to give you the day they stopped bleeding, but you need the very first day that they start bleeding. And we use a process called Naegele's rule, which we'll discuss in just a minute. We can also use other physical assessment tools to estimate where a patient might be in their pregnancy and use that to determine the due date. One method is called McDonald's where we measure the uterus and we match the measurements of the uterus with their gestation.

00:59 Another method we can use is to just simply ask the patient "What kinds of symptoms are you feeling?" So, one symptom called quickening, again is when the patient first perceives fetal movement, happens at around 18 weeks. So for example if a patient comes in and says "I haven't felt my baby move or I felt my baby move 2 or 3 weeks ago, you can make an estimation about how far along they might be and then use that information to determine the due date. We can also use perhaps the easiest method which is an hCG. So this can be done through the urine or through the blood to look for a hormone called human chorionic gonadotropin that's released by the conceptus. If it's present, it also will let us know if the patient is pregnant. The most popular, usually, however is an ultrasound. So, an ultrasound, if you remember, is a positive sign of pregnancy so that's good. But we can also use parts of the fetus, the crown rump length, the abdominal circumference, the chest circumference, and we can determine a due date based on those measurements. So, those are several ways that we can use to determine the date of a pregnancy. Now, I mentioned doing a physical assessment in terms of sizing the uterus for McDonald's, but we can also size the uterus when it's still a pelvic organ, when it's tiny. So, if you compare the size of a uterus during a bimanual exam to a tangerine, then that's about the size of a 6-week pregnancy. When you get to be about 8 weeks, the uterus is about the size of a baseball; 10-week uterus is about the size of a softball; and a 12-week uterus is about the size of a grapefruit. So, not a teeny tiny anemic grapefruit, but a nice big Texas grapefruit. Okay. Now, let's think about dating the pregnancy with the last menstrual period. I told you I would show you our step and I'm going to do this. Now, I apologize because we do believe in torturing nursing students. This is usually at this point done most often on a computer program or app on your phone, but I'm going to take you the long way so just go with me. It's going to be okay. So, we ask that question "When is the first day of your last menstrual period?" Once we get that date, then from that date we subtract 3 months, we add 7 days and then we add a year and that will give us the estimated date of delivery plus or minus about 2 weeks. And we'll have to work through when to add a year and when not to add a year because if we add a year to an LMP that's in January, February, or March you would actually be pregnant about 2 years which I think is about the length of an elephant's pregnancy but definitely not human. So, let's try it with an example. The patient tells us their first day of their last menstrual period is June 18, 2020. We subtract 3 months from June, we add 7 days to the 18th, and we add a year because the LMP is not January, February, or March and then we come up with an estimated due date of March 25, 2021. So after we get past to establishing the due date, the next thing we need to do is begin to take a history. So, knowing what a patient's previous history was and how things went with previous pregnancies will help us determine what would be the best way to care for this patient and their family during pregnancy. So I'm going to teach you some terms to kind of work through that process and this will help with the next thing we're going to do. So, gravidity or gravida, you've seen that word before but it stands for the number of pregnancies someone has had. Now it doesn't matter if this has been confirmed by a provider or if the client comes in and says "I've been pregnant twice before," we use whatever it is that they tell us. So that's going to be the first definition. The next one is parity, P, this stands for the number of pregnancies that were delivered after 20 weeks of gestation. Sometimes we don't know the gestation and we'll use the weight of the products of conception and that weight is 500 grams. But for the most part, we know the gestation so any pregnancy that goes beyond 20 weeks we count that under parity. A nulligravida, you remember no meaning zero, is a client that's never been pregnant before. A primagravida, prime meaning first, is a client's first pregnancy. A multigravida is a client who's experienced 2 or more pregnancies. We've talked about and broken down gravidity or number of pregnancies, now let's break down parity. What happens in terms of the delivery. In order to make this part make sense, we've got to go over 1 more vocabulary word and that is viability.

05:52 Viability is a term that refers to whether or not the fetus can survive outside the uterus. So, a 16, 17, 18-week fetus would be too early, too premature in order to be able to live outside the uterus. On the other hand, a pregnancy that goes to 25, 26 weeks and up, that baby with some support from the providers would actually be able to survive and therefore would be called viable or that is viability. Nullipara, back to the words we know, no meaning not, para meaning babies that have come out, a client that's never had a pregnancy beyond the stage of viability, so never had a birth that's beyond viability. Primipara, client has been pregnant once beyond the stage of viability, therefore has delivered a baby beyond viability. Multipara refers to a client that's been pregnant at least twice beyond the stage of viability. So, these terms refer to parity. Okay, we've talked about gravidity and parity and all the terms, so now we're going to put it together. Remember we said earlier that we were going to use these to take a history, so now I'm going to show you how we do that. We use a 5-step system called GTPAL as a way to know how many pregnancies and also what happened, what was the outcome of those pregnancies. And this will help us predict and take care of a patient during their pregnancy. So let's break it down. Gravidity stands for the number of pregnancies.

07:26 Remember, doesn't matter whether the patient tells us or whether we can confirm it with records, we count it. T stands for term. Term is greater than 37 weeks. So, not the number of babies. So you might be thinking what happens if I have triplets or quadruplets, or octuplets.

07:44 It doesn’t matter, it's the number of events. So term, the number of termed deliveries, not babies. Preterm stands for the number of births after 20 weeks, okay, but before completion of 37 weeks.

07:57 And in that timeframe, again, events not number of babies, counts as preterm. Abortion is an umbrella term that we use in healthcare to really refer to any kind of loss. So whether the loss is spontaneous or it's an elective procedure, it counts as an abortion. So other things will fit under abortion as well for the purpose of this exercise; ectopic pregnancies, tubal pregnancies. Again, events not babies that are involved in that situation count under A for abortion. And then the last one, living, refers to the number of currently living children.

08:36 That's a lot. You may need to rewind and go back to that again or pull out your textbook that's completely fine because now we're going to test and see if we've got it. Here we go. We have a new patient presents at 12 weeks with the following history. Twins at 32 weeks, a miscarriage at 10 weeks, an elective abortion at 6 weeks, and the patient has also delivered a singleton at 38 weeks. And just to note, singleton just means 1 single baby in utero as opposed to twins or triplets. So let's see how we did. First of all, the G is 5, the patient is pregnant now so that counts as 1, the twins counts as 1, the miscarriage counts as 1, the elective counts as 1, and the delivery of the 38-weeker counts as 1 so that gives us the 5 under the G. Term, so we're looking for the number of deliveries after 38 weeks and it looks like we only have 1, the singleton. Preterm is going to be between 20 and before 38 weeks and it looks like we also only have 1. Now we have twins but because we're counting events and not babies it only counts as 1. Under abortion, we have 2 events. So we have the elective abortion at 6 weeks and we have the miscarriage at 10 weeks. So each of those are separate events, so we get a 2 for that. Now we get to the L and we get to catch up with the twins and figure out where they are and we can count each of the twins as a separate event so we have twins (1, 2) and the singleton and that gives us a 3. So when we report out, we would say that this patient is a G5, T1, 2, 3. Another thing that's important to understand is the fact that the pregnancy is divided up into trimesters, and we want to understand this because we throw this jargon out a lot and we want to know what we mean. So, tri means 3 but let's see how it's broken out in terms of weeks. So from week 0 all the way to week 12, that's considered the first trimester. The second trimester goes from 12 weeks all the way up to 28 weeks and the third trimester goes from 28 weeks all the way to the end of pregnancy.

10:53 They're not exactly evenly balanced but those are the terms and it's really important that we break this up because certain testing is done during certain trimesters and we have to know when that is.