BUTTE COUNTY PUBLIC HEALTH DEPARTMENT POLICY & PROCEDURE SUBJECT: Pregnancy Testing and Counseling Protocol P&P # APPROVED BY: EFFECTIVE DATE: Mark Lundberg MD Health Officer REVISION DATE: 2/20/2010 Phyllis Murdock Director Public Health Purpose: To provide women and their partners with the information and support needed to make an informed decision in a safe and non-judgmental environment regarding their reproductive health care when pregnancy is suspected or confirmed. To diagnose early pregnancy, to diagnose a health problem that may have negative consequences on a client s health, fertility, or may be life threatening (eg ectopic pregnancy). To facilitate appropriate medical care including prenatal and pregnancy termination. To provide information needed to enable clients to make an informed decision most compatible with their emotional, spiritual and physical well-being and beliefs. Policy: Clinic PHA s, LVN s and RN s will perform pregnancy testing and when the pregnancy test is positive, offer information about all pregnancy options in an unbiased manner. Staff will also provide client education regarding methods of birth control as appropriate and in an unbiased manner. Procedure: Test information: Pregnancy tests work by measuring a hormone called human Chorionic Gonadotropin (hcg) produced by pregnant women. After a fertilized egg implants in the uterus, the hcg from the conception enters the woman s blood stream and soon appears in her urine. It is sometimes possible to detect hcg before a woman s next period is expected but usually tests are used after a woman misses her menses. As pregnancy progresses, more hcg is produced and it becomes easier to confirm positive test results. Ovulation occurs approximately two weeks before a woman s period. Pregnancy testing is done using a urine test. False positive results can occur after a recent miscarriage or pregnancy, or if the woman is on hcg injections for dieting or fertility. High levels from these injections can last for up to a month following treatment. False positives can occasionally occur from protein in the urine of women with diabetes, kidney disease or on various forms of weight loss programs, particularly high protein diets or ones where clients are fasting.
False negative results when the woman is pregnant can occur in about 10% of clients. ** A pelvic examination is recommended when pregnancy test results are not compatible with history or physical symptoms, gestational age is questionable or medications and/or drugs have been used that affect pregnancy test results. ** If the patient requests a blood test for pregnancy inform them that the early urine pregnancy test can be as reliable as serum pregnancy test and they will have to pay for a serum test. The blood test is generally ordered when a clinician wants to rule out an ectopic pregnancy. The result won t be available until the next day. Signs and Symptoms of pregnancy: Late period, breast tenderness, fatigue, nausea/vomiting, weight gain, frequent urination, slight increase in temperature, increase in vaginal discharge, protruding lower abdomen after 12 weeks, fetal movements after 18 weeks. Patient assessments: Clinic staff meets with the patient, review the patient health history for prior medical conditions, pregnancy symptoms, contraceptive status, last normal menstrual cycle, menstrual regularity, medication, birth control or drug use. Staff confirms whether or not she is seeking a pregnancy test. Clinic staff performs the test; results are given privately to the patient. Staff must clearly define the terms positive and negative to the patient, stating clearly if she is or is not pregnant. Clinic staff presents options that are discussed in an unbiased manner. Information on all options should be provided to each patient so that she will have relevant resources should she change her mind. Positive Test Results: 1. Clients with a positive pregnancy test will be told they have a positive test that means they are pregnant and will be asked how they feel about the test results. 2. Define the limitations of the test as appropriate, for example if she has recently had a baby, miscarriage, or abortion. The woman s medical history should be reviewed. If the review is done by the PHA, the PHA will review the abnormal findings with the clinician/nursing staff who will then provide guidance. 3. Gestational age of pregnancy as determined by menstrual history will be determined with the woman. 4. Women with poorly defined dates, with bleeding and/or pelvic pain, on drugs affecting pregnancy test results, and near menopause may be scheduled for a pelvic examination to determine the length of the pregnancy. 5. If the pregnancy is planned, offer congratulations and ask her how she feels about the pregnancy. Provide client with a referral with all options in case she changes her mind in the future. Clients who elect to continue the pregnancy should receive a referral for early initiation of prenatal care and given a positive pregnancy packet. They should also be asked if they want to be contacted by the Prenatal Care Guidance
Registered Nurse. A brief review of packet materials and good health practices during early pregnancy is provided: eg, good nutrition, initiation of prenatal vitamins, avoidance of smoking, drugs and exposure to x-rays. If the client has a medical problem or is taking a medication that may prove harmful to a pregnancy this is an opportunity to discuss the issue with one of the clinicians. If the client needs case management services a referral to the TCM program will be completed. 6. If the pregnancy is unplanned and the patient decides to continue the unplanned pregnancy: Explore her feelings, ask how she feels, and validate her concerns. Discuss the full range of options, including continuing her pregnancy, adoption and abortion to give her a chance to consider all her alternatives. Provide her a referral list including all options should she change her mind later. Referral to the Prenatal Care Guidance and case manager will be offered, same information as for planned pregnancy. Inform the client that she can come back to the clinic for information if she wishes, and that the Prenatal Care Guidance nurse can work with her as needed. 7. If the patient is undecided: Encourage open discussion of the woman s feelings she may be overwhelmed and confused. Provide the chance for her to talk about the various reasons and life situations she is dealing with. Offer that she can speak with the Prenatal Care Guidance nurse to address her concerns. Provide the patient with options including the time constraints for a first or second trimester abortions if she is considering that choice. Calculate how many weeks have passed since her last normal period. 8. If the patient wants an abortion: Discuss her rationale on how she came to this decision, validate her concerns, discuss full range of options, and provide written information. Discuss possible risks of the abortion procedure; bleeding, infection, cramping and discomfort. Inform her of the approximate cost. Discuss birth control options, specifically; what is her plan for contraception after the abortion. Points to remember when counseling a patient considering abortion: Use open ended questions, listen carefully with compassion. Don t judge or try to make decisions for the patient. Provide objective information and support. Be aware of your own biases. Do not rush the woman to make a decision. Allow the opportunity to discuss her other issues as time permits. Present the option of a second counseling session with the Prenatal Care Guidance nurse. Do not enter a counseling session with the conclusion that the patient will have an abortion, instead, focus on the fact that she is pregnant and has
three options including abortion, carrying the pregnancy to term and keeping the baby or placing the baby up for adoption. 9. If the patient decides to give the baby for adoption: Discuss with the patient the reasons for making this decision. Has she looked into this option and does she know what it entails? Provide her with information she needs to understand the procedure. Provide the client with referral information for Adoption Choices of Northern California. Discuss full range of options including abortion and keeping the pregnancy in order to give her a chance to consider all alternatives. Provide her a referral list that includes all options in case she wants to change her mind later. Discuss how she will feel carrying the pregnancy to term and then giving the baby up. Include the positive and negative feelings she is experiencing as a result of making this decision. Encourage her to begin prenatal care as soon as possible and remind her that she can return for further counseling with the Prenatal Care Guidance Nurse as well as complete the referral for the Prenatal Care Guidance nurse to begin working with the patient. This will assure the patient is able to receive prenatal care and will have follow up information. Suggest she begin taking prenatal vitamins daily, encourage her to avoid smoking, alcohol and any drugs, encourage avoiding starting any medication until she checks with her clinician first. 10. Negative Test Results: The routine phrase to use is: The results of your pregnancy test are negative, which means that you are probably not pregnant. * A clinician evaluation will be conducted when the pregnancy test is negative but the client experiences shoulder pain, spotting, bleeding, abnormal discharge and/or fever or if she has normal signs and symptoms of pregnancy. If a woman is disappointed and wants to become pregnant; acknowledge her disappointment and help her plan next steps. Review her medical history, including menstrual cycle and medications. If she is less than 2 weeks from the time she expected her period, encourage her to return for retesting. Also, define limitations of urine test and explain the possibility of false negative responses that may require retesting. If the client is trying to conceive: Ask the patient how long she has been trying to conceive. Determine when in the cycle she usually has intercourse. It is important to know if the couple is having intercourse during the fertile time and number of times they intercourse at this time. Review how to determine the fertile time. Refer to infertility services if the woman has a history that may indicate she could have a fertility problem, her partner has never had a child, has a history that could indicate a fertility problem or has not had a semen analysis or if the client is over 30 years of age and has been trying to conceive for at least 6 months. Staff should consider referring this client to a clinician who will determine appropriateness of infertility referral at that point. If the client has been trying to conceive for less than a year encourage her to continue trying and discuss stressors in her life that may adversely affect the
process. Illness, stopping hormonal contraceptives, changes in diet and/or exercise, also may delay a woman s period. If it has been over one year, offer a referral for infertility services. Encourage her to start prenatal vitamins and use them for 3 months or more before she conceives, and avoid smoking, drugs and alcohol. Offer preconception counseling. If the client is not trying to conceive; evaluate causes for delayed menses including the possibility of false negative test results. Ask her to return to the clinic in 2 weeks for a repeat pregnancy test. If the test is negative at that time, the client must be referred to a clinician for evaluation. Review her current contraceptive method, how long she has used it, does she have any problems using it. If she has a method she does not like, discuss alternatives. Provide written information regarding the available contraceptive methods. Schedule a visit with the clinician if she wishes to. Assess STI risks, offer testing for at risk women, encourage use of condoms and foam, review safe sex practices. 10. Preconception Care and Counseling: Although most of the patients seen at clinic are concerned with preventing or postponing a pregnancy, it is important to address healthy pregnancy through education and counseling in the family planning setting. The purpose is to optimize a woman s health to reduce medical risks during a pregnancy for a healthy pregnancy and birth outcome. Almost half of pregnancies are unplanned. These pregnancies are at higher risk due to risky behaviors, unhealthy diets and exposure to substances while the women are unaware of their pregnancy. F-Pact pays for preconception counseling; the woman can schedule a visit for this. Teachable moments occur when the woman is at the clinic for pregnancy testing. Preconception care can be thought of as interventions used throughout a woman s childbearing years, even when there is no plan for pregnancy. This also involves focus on spacing of pregnancy. A short period of interconception (time between pregnancies) is considered to be 18 months or less. It is advised that women space pregnancies by at least two years to allow their body and next pregnancy to be optimum. A reproductive life plan can be discussed which allows the woman to set her own goals and plans regarding planning her family. This is based on her values, current resources and knowledge of family planning, reproductive health and preconception care. Questions to ask: Do you want to have a baby at some point in your life, if so when might you want to have the baby? I see you are not using your method- are you thinking about having a baby? What are you currently doing to prepare for a future pregnancy? What can I do today to help you achieve your plan?
As a Public Health clinic this gives the client the opportunity to use our women s wellness assets and a complete history and physical determine needed services such as: pap, STI testing, preventive health messages on : smoking cessation, substance misuse/abuse, weight loss, nutrition/exercise/stress management, domestic violence, child sexual abuse screening. Folic acid and/or prenatal vitamins are discussed with the patient and she should be informed these need to be taken at least three months before conceiving. Discuss the importance of receiving regular prenatal care throughout the pregnancy. Discuss non-chronic health issues such as gum inflammation/infection, untreated cavities/decay. There can be serious pregnancy related complications associated with dental disease such as preterm delivery, preeclampsia, and low birth weight. Provide educational materials about tooth-brushing and mouthwash. References: Integrating Preconception Care Into Your Practice: CFHC 2009 March of Dimes: Preconception Care most recent guideline American Journal of Obstetrics and Gynecology 2008 Patient Education and Counseling Protocol Los Angeles Harbor UCLA Medical Center, Anita Wilson MD Update 5, 2009