MANAGEMENT OF THE: PREGNANCY *
. _ TESTTNG ENCOUNTER [ _
THE DEMANN ALGORITHM ; .

“ DONNA J. DE MANN "

MICHTEAN STATE UNIVERsTTT ,
MASTER or SCIENCE TN NURSING 7 _- p 7 ‘
' COLLEGE OF NURSING _ - ‘

. .1999

 

 

 

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MANAGEMENT OF THE PREGNANCY TESTING ENCOUNTER:
THE DEMANN ALGORITHM

By

Donna J. DeMann

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1 999

ABSTRACT

MANAGEMENT OF THE PREGNANCY TESTING ENCOUNTER:
THE DEMANN ALGORITHM

By
Donna J. DeMann

There are many opportunities to intervene in the lives of women at the time of the
pregnancy testing encounter. Interventions could include one or more of the following:
preconception care, infertility services, pregnancy options counseling, evaluation for
amenorrhea, prenatal care, or family planning. While the pregnancy testing encounter is
often viewed as simply a time to perform a pregnancy test, it should be viewed as a
complex contact which requires in-depth knowledge, assessment and critical thinking in
order to best serve the needs of the woman seeking a pregnancy test. This project presents
an algorithm to guide the advanced practice nurse (APN), when assessing and offering
interventions at the time of pregnancy testing. APNs must utilize evidence-based practice
in order to deliver quality health care to the clients. The DeMann Algorithm, which is
based upon current research and is guided by Starfield's Health Service System Model for
primary care service delivery, provides the APN with a systematic approach in responding
to a woman's request for pregnancy testing. The algorithm can be utilized by other health
care providers, i.e., physicians and physician assistants, and its use can decrease health
care costs and enhance health outcomes for women and their families. Health care
agencies which provide pregnancy tests can also The DeMann Algorithm; this action

should promote more comprehensive services at a crucial time in a woman's life.

Copyright by
Donna J. DeMann
1999

iii

 

With love to Greg.

iv

ACKNOWLEDGMENTS

My sincerest thanks to the chairperson of my committee, Joan Wood, RN, PhD. I
appreciate all of the encouragement, time, and assistance that Joan ofl‘ered throughout this
project. I would also like to thank my committee members, Rachel Schiffinan RN, PhD
and Brigid Wanen RN, MSN for the input and expertise that they gave to this project.
Finally, I would like to thank Dorothy Sharp, without her, I may have never learned the

value of education.

TABLE OF CONTENTS

LIST OF FIGURES ................................................... viii
INTRODUCTION ................................................... 1
PURPOSE OF PROJECT .............................................. 2
CONCEPTUAL FRAMEWORK ......................................... 2
APPLICATION OF THE STARFIELD MODEL TO THE PROJECT ............ 5
LITERATURE REVIEW .............................................. 9
Algorithms in Health Care ........................................ 9
The Negative Test as an Opportunity to Provide Preconception Care ........ 11
The Negative Test as an Opportunity to Offer Contraception Services ....... 11
The Negative Test as an Opportunity to Assess Amenorrhea .............. 12
The Negative Test as an Opportunity to Provide Infertility Services ......... 13
The Positive Test as an Opportunity to Options Counseling ............... 13
The Positive Test as an Opportunity to Offer Abortion Services ............ 14
The Positive Test as an Opportunity to Prenatal Services ................. 14
ALGORITHM DEVELOPMENT ........................................ 15
Assumptions .................................................. 16
The Primary Assessment of the Woman Seeking Pregnancy Testing ......... 16
The Woman with a Negative Pregnancy Test .......................... 19
The Woman with a Positive Pregnancy Test ........................... 22
The Woman Using Oral Contraceptives .............................. 24
The Woman Using Depo-Provera ................................... 29
The Woman Using Norplant ....................................... 32
The Woman Using an IUD ........................................ 35
The Woman with a Tubal Ligation .................................. 37
IMPLICATIONS .................................................... 40
Implementation of the DeMann Algorithm into Practice .................. 40
Research ..................................................... 42
Education .................................................... 43
Practice ...................................................... 44

vi

CONCLUSION ...................................................... 46

REFERENCE MATERIALS ............................................ 47
Appendix ..................................................... 47
List of References .............................................. 48

vii

LIST OF FIGURES

Figure l - The Health Services System Model ............................... 4

Figure 2 - Modified Health Services System Model Applied to
the DeMann Algorithm ........................................ 6

Figure 3 - The DeMann Algorithm: The Primary Assessment of the
Woman Seeking Pregnancy Testing ............................... 17

Figure 3a - The DeMann Algorithm: The Woman with a Negative Pregnancy Test . . . 20

Figure 3b - The DeMann Algorithm: The Woman with a Positive Pregnancy Test . . . . 23

Figure 3c - The DeMann Algorithm: The Woman Using Oral Contraceptives ....... 25
Figure 3d - The DeMann Algorithm: The Woman Using Depo—Provera ........... 30
Figure 3e - The DeMann Algorithm: The Woman Using Norplant ................ 33
Figure 3f - The DeMann Algorithm: The Woman Using an IUD ................. 36
Figure 3g - The DeMann Algorithm: The Woman with a Tubal Ligation ........... 39

viii

Introduction

"The classic evidence of early pregnancy in women is the secretion of (hCG)
human chorionic gonadotropin by the placenta (Wasley, 1988, p. 42)". Pregnancy tests
measure changes in levels of the hCG to determine pregnancy viability and status (Pernoll,
1991). Women and health care providers (HCPs), i.e., advanced practice nurses (APNs),
physician assistants (PAS), and physicians, rely on pregnancy tests for early pregnancy
diagnosis. While the pregnancy test is generally perceived as an innocuous test, the
process of pregnancy testing requires considerable assessment in order to identify a
woman's needs and promote her health and the health of her family. Due to the complex
nature and the implications of performing a pregnancy test, HCPs need to manage the
pregnancy testing encounter in a manner which reSponds to the needs of the woman and is
based on empirical evidence.

Problem Statement

Current pregnancy test practices are failing women. The pregnancy testing
encounter is a critical moment in a woman's life; the encounter offers many opportunities
to assess the needs of women and to provide interventions appropriate to her needs.
Unfortunately, HCPs do not view pregnancy testing as a complex task and some tests are
ordered strictly based on the woman's request for a pregnancy test. Current practices have
resulted in increased health care costs related to inappropriately ordered tests which are
either inaccurate, need repetition or are unnecessary. This practice pattern has resulted in
missed opportunities to offer services to women which could optimize their health status
(Jack, Culpepper, Babcock, Kogan, & Weismiller, 1998).

Health care providers interacting with women at the time of pregnancy testing
must possess a substantial knowledge base. The HCP must use the most current
knowledge to determine when and if to perform the pregnancy test. The HCP must assess
the needs of the woman who is having a test, e. g., her desire to continue the pregnancy
and offer interventions and referrals appropriate to the woman's needs. Many possible

I

interventions exist. The woman with a negative test may need intervention for secondary
amenorrhea, contraception, infertility, or preconception care. The woman with a positive
test may need services for abortion, adoption, prenatal care, and/or she may need
counseling to explore her options.

Despite the complexity of pregnancy testing, there are health settings which allow
support staff, e. g., medical assistants (MA's) and licensed practical nurses (LPNs) to order
pregnancy tests (Jack, Campanile, McQuade, & Kogan, 1995). While support stafi‘ may be
capable of assessing the last menstrual period and the date of possible conception, support
staff typically do not have the knowledge base to further assess the woman and her
presenting concern, to intervene when test results are delivered to the woman, and to
advise the woman when interventions are necessary.

There is also a lack of standardization among HCPs when assessing a woman and
ordering the pregnancy test. This may be due to complacency and/or the HCP's belief that
the pregnancy test is innocuous. There is current need for the development of a systematic
process which guides HCPs during the pregnancy testing encounter.

Purpose of Project

The purpose of this project is to develop an algorithm to guide HCPs, specifically
the advanced practice nurses (APNs), actions and interventions at the time of pregnancy
testing. The algorithm offers direction to the APN on the assessment of when and if the
test should be performed, on the assessment of the woman's needs regardless of the test
results, i.e., positive or negative; and provides guidance on the proper interventions or
referrals to meet her needs. Since all APNs do not have the same experience or knowledge
base, the algorithm provides guidance to APNs to assess/intervene more thoroughly.

Conceptual Framework

Starfield ( 1973) proposed that there are four factors that effect an individual's state

of health. The factors include: genetic structure, social and physical environment,

individual behaviors, and health services. In 1973, Starfield combined these factors with

Donabedian's (1966) classification of health services variables, i.e., structure, process, and
outcome, to produce the Health Services System Model. Starfield proposed that for the
health care system to be effective, it had to include aspects of each of Donabedian's
variables and the factors which effect the individual's state of health. In 1992, she revised
her model (see Figure 1). The new model added three additional components to the
structure variable which are characteristics of services but are unrelated to clinical care.
She firrther described the several components which make up each variable of the health
care services.

The structure variable describes the components that enable the health services
system to provide services. It includes the following components: (a) personnel: the
number, type, training and motivation of each person delivering care; (b) facilities and
equipment: the number and type of facilities, the accreditation, and the standards; (c)
range of services: the kinds of services offered; (d) organization: the mechanisms for
coordination, accountability, and responsibility of personnel; (e) continuity: the
mechanisms for follow-up and communication with other entities of the health care
system, i.e., laboratories, specialists; (f) accessibility: the ability of the patients to reach
services; (g) financing: the method of payment by patients for services and employees for
their work; and (h) population eligible: the people eligible for services.

The process variable includes two major components which have their own
subcomponents. The first, provision of care, refers to the activities of the provider and
includes: problem recognition, diagnosis, management and reassessment and the second,
receipt of care, refers to the activities of the client, i.e., utilization, acceptance and
satisfaction, understanding and compliance.

The outcome variable reflects the impact of the structure and process variables on
one's state of health. There are seven components of outcome. The components are rated

on a continuum and include: (a) longevity, the life expectancy of the individual;

 

Personnel

Facilities and equipment
Range of services
STRUCTURE Organization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Management/amenities
Continuity ‘
Accessibility
Financing
Population eligible H
Problem recognition i
{ Diagnosis
Provision Management
of Reassessment
Care A
Social
Persons ¢ and
Physical
PROCESS ‘T N Envir
Utilization
Receipt Acceptance and satisfaction
Of Understanding
Care Participation
Longevity
Activity
Comfort ‘_,
OUTCOME Perceived well-being
Disease
Achievement
Resilience

 

 

 

Figure l. The Health Services System Model (Starfield, 1992).

5

(b) activity, the individual's ability to carry on normal activity; (c) comfort, the pain or
other sensations which interfere with work or pleasure; (d) perceived well-being, the view
a person has of their own health and their satisfaction with it; (e) disease, the presence of
conditions which potentially or actually interfere with the individual's physical and/or
mental well-being; (f) achievement, the level of development or accomplishment and the
potential for future development of better health; and (g) resilience, the ability to cope
with adversity and the potential for resisting a range of possible threats to health.
Application of the Starfield Model to the Project

Starfield's Health Services System Model provides a good framework for
evaluating the care provided in the primary care setting (Starfield, 1992). While algorithms
are not specified in this model, they have been utilized to improve the quality of care, as
well as to decrease the cost of care. In order to solve a problem, an algorithm offers
specific orderly steps, with decision points to direct the user to the solutions. An algorithm
can decrease the potential for fragmented care (Bridgeman, Flores, Rosenbluth, Pierog, et
al., 1997). In order to utilize the proposed algorithrn in the health setting, structural
components must be in place, but, because an algorithm directs the provision of care, the
proposed algorithm is specifically placed within the process variable in The Health
Services System Model (see Figure 2).

The algorithm is written for APNs for utilization at the time of pregnancy testing.
Schaffner, Ludwig-Beymer and Wiggins (1995) define APNs as nurses who have
fithhered their education to perform advanced assessment, nursing and medical
diagnosis, and interventions. APNs provide care which emphasizes early intervention and
ongoing management and encompasses several categories of care providers including
nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified
registered nurse anesthetists (Schaffner, Ludwig-Beymer, & Wiggins, 1995). The working

definition of APN for this project is a nurse who has had formalized education

 

 

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Figure .

 

Personnel:
APN
Facilities and equipment:
Primary Care F acility/T esting equipment
Range of services: Pregnancy Testing
STRUCTURE Organization:
Credentialling/ColIaboration of team
Management/amenities:
Reporting of test result/Customer Service
Continuity:
Follow-up procedures
Accessibility:
Availability for appointments
Financing:
Aflordability of services/insurance acceptance
Population eligible:
Women seeking pregnancy testing
A ( Problem recognition:
L { Assessment of woman ’s needs
G Provision Diagnosis:
0 of Identification of specific needs
R i Care Management:
I (APN) Intervention/referral for specific needs
T Reassessment:
H L Follow-up
M
3 Social/
Persons Physical
PROCESS " Environment
Utilization:
Use of facility
Receipt Acceptance and satisfaction:
of Willing to receive care
Care Understanding:
(Client) Knowledge base
Participation
Willingness to answer questions
honestly/completely, willingness to return for
K interventionsfl’ollow-up
Longevity: GOALS.-
Activity: *lncreased education of women
Comfort: *lncreased/earlier prenatal care
OUTCOME Perceived well-being: *Increased preconception care
Disease: *lncreased care of non-pregnancy related
Achievement: . amenorrhea
Resilience: *Increased contraception care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘lncreased infertility care

‘lncreased options counseling

 

Figure 2. Modified Health Services System Model Applied to the DeMann Algorithm.

 

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in either a graduate, or a certification program and is prepared to perform advanced
assessment, formulate nursing and medical diagnosis, and implement advanced
interventions. Within Starfield's structural component is the personnel variable. Starfield
defines personnel as the individuals involved in the provision of services. For the purpose
of this project, personnel refers to APNs who utilize the DeMann Algorithm to provide
services to the woman at the pregnancy testing encounter. The pregnancy testing
encounter for this project is defined as the contact between the APN and client, i.e,. in
person or by phone, when a woman indicates her interest in having a pregnancy test.

Within the structural component of Starfield's model, is another variable, the
WWW which refers to the types, equipment, accreditation, and the
standards of the facilities. While this project is not specifying a specific health setting in
which to perform pregnancy testing, the health setting will need either a contract with a
laboratory or access to the test kits available to carry out the pregnancy test.

Starfield's model describes the W5 as the types of services offered.
The tangeofsondoes specified by the algorithm is pregnancy testing. Pregnancy testing
refers to the encounter between the APN and the client, in which a request for a
pregnancy test, i.e., the APN and woman interact to determine the need for the test, a
serum or urine test which identifies hCG (Wasley, 1988) is performed, and if the test is
performed, the interventions necessary to meet the woman's needs are identified.

As appropriate to Starfield's model, accountability and responsibility of the APN
are part of the organizational component. This recognizes that the facility must have a
mechanism for credentialing APNs in order to insure that they are properly prepared to
follow the algorithms and to collaborate, consult with or refer to other health care
providers. The facility must have managemenLandamenities established to insure timely
reporting of the pregnancy test result and to insure that clients are treated with courtesy
and respect. The facility must have mechanisms to ensure follow-up when the patient is

referred to an outside agency to ensure continuin of care. The facility needs services

which are accessible and affordable to the woman seeking a pregnancy test. And finally,
the populationfihgible as specified in the algorithm refers to the women seeking a
pregnancy test.

The structural components which are reflected in this project include the
personnel, the range of services, and the population. The main focus of the project.
nonetheless, is the algorithm which fits within the process variable.

Algorithms are defined in different ways. Costello (1991) define an algorithm as a
formula or set of steps for solving a problem. Bridgeman, et al. (1997) define an algorithm
as a decision tree. Gonthier and Habel (1994) define an algorithm as a systematic, step-by-
step visual representation of a decision-making process, which describes the essential parts
of a process and poses questions to be answered in solving a problem or completing a
project. Clinical practice guidelines are also stepwise evaluations of either a diagnosis or
management strategy (Hoyt, 1997); protocols are plans or rules for carrying out a client's
treatment regimen (Costello, 1991). For this project the distinguishing factor of the
algorithm is that it is a visual representation, of a decision-making process, which involves
assessment, diagnosis, and intervention, in order to address a problem. Thus, algorithm is
the term selected to describe the proposed project, and Gonthier and Habel's definition is
selected as the working definition for this project.

Starfield's process variable is broken down into two components, the provision of
care, and the receipt of care. The algorithm offers assistance to the APN in the provision
of care. The systematic, step-by-step visual representation leads the APN through problgm
magnition to make decisions which will assist in reaching a diagnosis and lead to
interventions/referrals within Starfield's treatmentlmanagement component.

For the process variable to be effective, according to Starfield's Model (1992),
there must be input from both the APN and the client. The same principal holds true when
considering an algorithm. The APN must ask the pertinent questions in order to obtain an

accurate assessment and to follow the pathways of the areas of need for mam

9

The client must provide accurate information and engage in honest communication so that
the assessment reflects the true needs of the client for meiptofoaro. The algorithm is a
main focus of the process variable, and although, the client's receipt of care is necessary, it
is not determined by the algorithm.

While the algorithm does not evaluate outcomes, an algorithm can facilitate
positive outcomes, decrease costs, and enhance collaboration (Bridgeman, Flores,
Rosenbluth, & Pierog, 1997). The goals for positive outcomes are related to maternal
and/or infant longevity, activity, comfort, perceived well-being, disease, achievement, and
resilience.

Pregnancy testing, although seemingly straight forward, can offer many
opportunities to the APN for assessment, problem/need identification and intervention.
The proposed algorithm placed within Starfield's Health Services System Model ofl‘ers a
process which the APN can follow which could have a significant impact on the woman
seeking care, her child/ten, and her family/significant other.

Literature Review

A review of the literature revealed no algorithms, guidelines, protocols or other
tools which address the comprehensive care of a woman seeking pregnancy testing. There
is, however, literature to support the use of algorithms in health care in general, and there
is evidence that pregnancy testing can be utilized for interventions which can enhance the
health of women. Algorithms in health care is discussed to support the use of an algorithrn
as a vehicle for this project; the Opportunities pregnancy testing offers the APN to assess
the needs of women and provide interventions are also included.

9] . l . II | I :

There is considerable literature which supports the use of algorithms in health care.

There is also evidence that positive outcomes can occur through the use of algorithms

(Akers, 1991; Hudzinski, 1995; Bridgeman, et al., 1997; Stengrevics, 1997).

IO

Bridgeman, et al. (1997), using a case management analyst, described algorithm
use in an emergency department. They found that patients: (a) with asthma had decreased
lengths of stay (LOS) from an average of 180 minutes to 94 minutes; (b) with diabetic
ketoacidosis had decreased LOS from 240 minutes to 130 minutes; and (c) with
gastroenteritis the LOS was decreased from 210 minutes to 77 minutes. This study also
found that there was better documentation in the client's chart and that the clinical
approach was more coordinated among caregivers when an algorithm was used.

Hudzinski (1995) in a case study format, evaluated the use of algorithms in a rural
hospice for cancer pain management. Two years of client situations were evaluated to
assess for evidence of increased interdisciplinary collaboration and communication, and
evidence of flexibility when dealing with individual clients. Hudzinski noted that in using
algorithms interdisciplinary collaboration and communication were increased and that
clients were treated with more flexibility. These circumstances resulted in a decreased
length of time for clients to receive pain management, i.e., from 24 to 48 hours to just one
to two hours.

Finally, Stengrevics (1997) cited the use of algorithms in caring for cardiac surgery
patients who had been sent home from the hospital. Algorithms were developed for the
most frequently occurring problems that home bound cardiac surgery patients encounter.
Weekly review of a log of 300 telephone calls revealed that the nurses had used the
algorithm, and that apprOpriate recommendations had been made by the nursing staff
Also, a case study analysis and client survey revealed improved client outcomes with 50%
of clients indicating that they had used the services, and 90-100% of the clients indicating
satisfaction with their care.

Algorithms have been used within the health care system, and have improved the
quality of care. An algorithm for APNs performing pregnancy testing has the potential to:

(a) decrease the number of inappropriately performed tests thus decreasing costs, (b)

ll

improve the assessment and interventions offered to women, and (c) theoretically, improve
the health of the woman, her unborn child/ten, or both.
I! ] I . I C . E . l E . C

The preconception literature suggests that there is a need for increased
preconception care. In 1990, the United States Public Health Service published Healthy

"er: m t. or. r. o' om u .u I' ‘r n 0.; '-.One
objective was: "Increase to at least 60 percent the proportion of primary care providers
who provide age-appropriate preconception care and counseling." Preconception services,
which are services to reduce the risk of adverse outcomes prior to conception, should be
offered to all women of child-bearing age. Preconception care has been documented to
produce positive outcomes in women with diabetes, women with phenylyketonuria (PKU),
and women with a history of a previous birth with a neural tube defect (Perry, 1996).
Summers (1993) wrote that just as counseling and referral are usually provided to the
woman with a positive test, preconception care and/or contraceptive counseling and care
should be provided to a woman with a negative test.

A study of preconception risks was completed by Jack, Campanile, McQuade, and
Kogan (1995). They Studied 136 women who had a negative pregnancy test, and
determined that 94% had reported at least one factor which required fiirther evaluation,
counseling or intervention before pregnancy. In this study, they concluded that the
negative pregnancy testing encounter is an Opportunity for preconception risk assessment
and counseling.

I] II . I : . E] E] C . S .

Contraception services include assessment and intervention to provide
contraception either pre or postcoitally. The statistic that more than 60% of pregnancies
are unintended indicates that contraception is an area of increased need which should be
addressed by professionals (W ard-Morgan & Deneris, 1997). It is estimated that as many

as 687,000 unintended pregnancies could be avoided with improved contraceptive method

12

use (Rosenberg, Waugh, & Long, 1995). Jack, Culpepper, Babcock, Kogan, and
Weismiller (1998) studied women with negative pregnancy tests and found that the
negative test is also a significant event and thus a time to address the contraceptive needs
of the woman.

SchwabeZabin, Sedivy, and Emerson ( 1994) studied the subsequent risk of
childbearing among adolescents with a negative pregnancy test. They found that 45% of
adolescents had a negative test result before their first pregnancy. The study looked at
2926 clients aged 17 and under and used a questionnaire format for assessment. They
noted in their study that in 1982 more than 2.5 million women under the age of 25
obtained pregnancy tests, and of the clinics studied, the rates of negative test results
ranged from 50%-88%. They further discussed the opportunities these negative tests offer
providers, i.e., to offer contraception services; they caution that the young woman whose
test is negative will require more intensive counseling if unintended birth is to be
prevented.

II 1 I . : . g g l

Amenorrhea can have physical as well as psychological ramifications for women,
and should be evaluated promptly and efficiently (Armstrong & South—Paul, 1996).
Amrstrong and South-Paul examined the causes of both primary and secondary
amenorrhea, i.e., ovarian failure, hypothalamic-pituitary failure, outflow tract obstruction
(imperforate hymen, uterine adhesions), uterine absence, and chromosomal abnormalities
and discussed their implications if left untreated. They provide the reader with an
algorithm to assist the provider to assess the client, to arrive at a diagnosis, to provide
appropriate, cost-effective care, and to make appropriate referrals. The article stressed the
need for accurate prompt diagnosis and interventions, the need to first rule out pregnancy

through pregnancy testing, and the need for further evaluation.

13

1.1 D 'E'IIE'I'S'

Ittner, Himmel, and Kochen (1997) studied whether the general practitioner is
interested in infertility counseling and whether the client seeks help from the family doctor.
Based upon the replies of 21 general practitioners, the authors noted that the practitioners
did not ask childless clients about their desire to conceive; however, the clients did believe
the practitioners to be an important source of information and advice. One-half of the men.
and one-quarter of the women studied expressed a wish that their doctor would have
asked about their desire to conceive, and expected emotional support from their general
practitioner. The authors concluded that providers must assess the infertility needs of
couples and offer interventions.

II E . . I I] . 33': D . C I'

There is support for the need for options counseling when a woman has an
unintended pregnancy. There are essentially three options when a woman becomes
pregnant: (a) continue the pregnancy to raise the child, (b) continue the pregnancy but
relinquish the child for adoption, and (c) terminate the pregnancy. The woman faced with
an unintended pregnancy faces a very difficult choice, and she may need support in making
her decision (Brien, 1996). A woman must be given information that will help her make an
informed choice, and she needs support for the intense emotions she may feel when a
choice is made (Lauderdale & Boyle, 1994; Resnick, 1992; Timpson, 1996).

Lauderdale and Boyle (1994) studied women who relinquish their child. They used
the knowledge that adoption causes feelings of loss and grief, and conducted a study
which examined the experience of infant relinquishment in open versus closed adoption.

They found that open adoption facilitated prenatal care and helped birthmothers make the
decision to relinquish with a sense of purpose and control, and enabled better coping
about the loss. They cement that given the facts that: (a) adoption can foster positive
outcomes for women, i.e., completed education, participation in the work force, delayed

marriage, and higher incomes, and (b) due to the differences in the experience of

14

relinquishment through open versus closed adoption, providers should be knowledgeable
about referral sources, help the woman make an informed choice and support the woman
in her choice.

Slonim-Nevo (1991) studied Israeli women who were temrinating their pregnancy,
their psychological experiences when facing abortion, and the types of assistance they
thought they needed. The study found that the most common feeling when faced with the
confirmation of the unintended pregnancy was that of sorrow. Other reactions cited were
those of surprise, nervousness, a wish to terminate as soon as possible, apathy, and mixed
emotions, i.e., happiness because they were fertile, yet sadness because the pregnancy was
unwanted. Once the woman decided to have the abortion, the overwhelming emotion was
fear of the procedure. The second part of the study looked at the services the woman
wished she had received at the time of confirmation of pregnancy, and before the abortion.
At confirmation of pregnancy, the woman wanted: (a) information about where to go to
have an abortion and how to fund it; (b) emotional support and comfort; (c) help in
making a decision; and (d) medical counseling. Before the abortion procedure, the woman
wanted: (a) information about the abortion procedure, risks and side effects; (b) emotional
support and comfort; and (c) humane treatment by the medical staff In conclusion,
Slonim-Nevo commented that any social worker, public health nurse, family physician, or
psychologist in health-maintenance organizations, high schools, women's shelters, runaway
shelters, and other welfare agencies should be able to provide the first phase of counseling
at the positive test encounter.

Studies show that a child born to a mother who has not received prenatal care will
be three times more likely to be low birth weight, and more likely to die before it's first
birthday (Machala & Miner, 1991). Roberts, Yawn, Wickes, Field, Garretson, and

Jacobsen (1998) studied barriers to prenatal care for women in a midwestem middle-class

15

community. This study showed that for 813 women aged 14-47 years, the crucial factors
in initiation of prenatal care were: the perceptions about the importance of prenatal care,
the ease of obtaining an appointment, and the ability to obtain child care for other children.
Lia-Hoagberg, Rode, and Skovholt (1990) also studied barriers and found that women
who had not planned the pregnancy or who viewed the pregnancy negatively were less
likely to seek early prenatal care and some did not seek prenatal care at all. Decreasing
barriers was identified as very pertinent to increasing prenatal care, as well as decreasing
maternal and infant mortality rates. These researchers emphasize that it is the role of the
provider who delivers the positive pregnancy test result to stress the importance of
prenatal care, to assist the woman in obtaining an appointment, and if possible to decrease
her barriers to prenatal care.

The literature review supports the use of algorithms in health care in general.
While the literature does not support a specific need for a pregnancy testing algorithm, it
does provide evidence which acknowledges pregnancy testing as a complex task which
offers many opportunities to APNs to intervene in a woman's health. This project's
product, the DeMann algorithm for the pregnancy testing encounter, recognizes these
opportunities and incorporates them into an algorithm to assist the APN.

Algorithm Development

Effective care of the woman seeking a pregnancy test means that the person
performing the test understands that the test encounter is not as simple as ordering the test
and communicating a positive or negative test result. The person performing the test must
be able to: (a) accurately identify if there is a need for the test, (b) assess the woman's
needs, (c) identify the possible interventions which can be offered to meet the needs of the
woman, and (d) either treat the woman's needs or make appropriate referrals when
necessary interventions are outside the APN's scope of practice. Thus, the creation of an
a180rithm should assist the APN in completing the above tasks. The DeMann algorithm
consists of a primary algorithm plus a series of secondary algorithms (see Appendix A for

16

the complete algorithm). The primary algorithm, Figure 3, The DeMann Algorithm: The
Primary Assessment of the Woman Seeking Pregnancy Testing, reflects the overall picture
of the woman's request for pregnancy testing, while Figures 3a-3f represent the secondary
algorithms' specific targeted subaspects. The decision making points within both the
primary and the secondary algorithms are supported by the literature, and are cited as each
algorithm is explained to the reader.

9 .

Two assumptions have been made in the development of the proposed algorithm:
(a) The algorithm addresses the encounter in which the woman requests a pregnancy test
from an APN, and (b) the algorithm does not apply to a pregnancy test to rule out
pathology, e. g., dysfirnctional uterine bleeding, and miscarriages.

IlE' ! El!!! Sl' E I'

The primary algorithm (see Figure 3) begins with the assessment of whether the
woman believes she is at risk for pregnancy. If she does not believe she is at risk, the APN
should assess why she believes she needs a test, and intervene/educate as necessary. If she
does believe she is at risk, the APN should assess if she is using a method of birth control
since birth control use poses special challenges for the APN. Hormonal contraception can
cause menstrual changes including amenorrhea while IUDs and tubal ligation can increase
a woman's risk of ectopic pregnancy and miscarriage if she becomes pregnant (Hatcher, et
al., 1994). The APN faced with these circumstances is directed to one of the other
algorithms within the series to address these issues appropriately.

Once contraception has been ruled out, the primary algorithm addresses the
assessment of the last menstrual period (LMP). The APN should assess the date of the
menses, the timing of the menses, the length of the flow, and the amount of flow. This
assessment is necessary to determine if the woman is indeed late for her period, or if there
have been changes which could indicate that she is pregnant (Hatcher, et al., 1994). Some

women will have implantation bleeding at approximately the same time a period is due.

17
Woman Requests a Pregnancy Test
i

 

 

Assess: Does she believe she's at
risk for pregnancy?
i t

-———+ W

 

 

 

 

 

s v
Oral contraception refer to Figure 3c
Depo«Provera refer to Figure 3d
Norplant refer to Figure 3e
IUD refer to Figure 3f
Tubal ligation refer to Figure 3g

+

Woman is not using one of the above methods of contraception

t
MIME;

Date: , is she late?
Tuning as expected?

Length as expected?
Amount of flow as expected?
Was menses "normal"?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mensa ls latepr Menses is on time and
abnormal "no 1"
iv
Perform Pregnancy Test ‘
ir 6
Positive N ative ls mew concerned about a recent
L j Leg J sexual experience?
+ s V
The woman with a The woman wrth a “es m
positive pregnancy negative pregnancy F *
‘est tes‘

 

 

 

 

 

 

 

m...
" Pm‘my? Wm
{v & heLneeds

AssessSemLLfistQm
Was sexual experience of
concern within the last

E I seve: days?

Test accuracy and date to

return to clinic for ‘—
' F

 

 

 

 

 

 

accurate testing. Discuss
abstinence from tobacco.

 

 

 

 

alcohol and other drugs. _ , _ ,
Discuss contraception if Inmate contraception services as
she is not seeking appropriate to woman's request
pregnancy.

 

 

 

m The DeMann Algorithm. The Primary Assessment of the Woman Seeking
Pregnancy Testing.

18

The implantation bleeding usually lasts for a shorter length of time and has less blood flow
than the normal cycle; and this may cause concern for the woman (Hatcher, et al., 1994).
A decision of the "normalcy" of her period is made based on the answers to these
questions. Normal is defined as the individual woman's usual menstrual cycle. The
algorithm then directs the APN based on the woman's response.

The APN assessing the woman whose menses is not late and has not changed, is
directed to assess why she believes she needs a test. Many women will present because
they are concerned about a recent sexual experience (Hatcher, et al., 1994). The APN
must address the woman's concerns, and is directed to proceed with appropriate
interventions if she has not had a recent sexual encounter of concern. The APN who
determines the woman is concerned about a recent encounter, is directed to assess
whether or not she desires a pregnancy.

The woman who desires pregnancy, yet has not missed a menses, is seeking the
test too early for the hCG to be detected. Human chorionic gonadotropin is not detected
until 10-14 days after conception (Pemoll, 1991), therefore, the APN must educate the
woman about the accuracy of pregnancy tests, and when to return to the health care
setting for testing. She should be encouraged to abstain from smoking, tobacco, alcohol,
and other activities which could cause harm to a pregnancy.

The woman who does not desire a pregnancy should be firrther assessed to
determine the date of the sexual intercourse which she believes places her at risk for a
pregnancy. Emergency contraception, i.e., postcoital contraception, may be an option to
reduce a woman's risk of pregnancy if coitus has been within the last seven days. The most
common emergency contraception is the use of hormone pills which reduce the risk of
pregnancy by 75% if the pills are given within 72 hours of intercourse (Ward-Morgan &
Deneris, 1997). Intrauterine devices can also be used for postcoital contraception up to
seven days after sexual intercourse. The postcoital IUD is thought to reduce the risk of

Pregnancy even more than hormone pills but is used much less frequently (Ward-Morgan

19

& Deneris, 1997). The postcoital IUD can cause increased risk of pelvic infection if the
woman has a sexually transmitted disease, and is not recommended in nulliparous women
(Ward-Morgan & Deneris, 1997).

The APN who assesses the woman and finds that she fits the criteria for
emergency contraception should discuss emergency contraception with her and offer
services if she desires to use one of the methods. The APN who assesses the woman and
finds she does not fit the criteria for emergency contraception should educate her on the
accuracy of pregnancy tests, when to return to the health setting for a test, about
contraceptive options available to her and when she should return to the health setting for
testing.

The APN assessing the woman who is late for her menses or whose menses is
"abnormal", should perform a pregnancy test. When the test is negative, the APN is
referred to Figure 3a, The DeMann Algorithm: The Woman with a Negative Pregnancy
Test; when the test is positive, the APN is referred to Figure 3b, The DeMann Algorithm:
The Woman with a Positive Pregnancy Test. These figures will be discussed in the
following sections.

II III . l I I . E I

The woman with a negative pregnancy test may have several needs, i.e.,
amenorrhea services, contraception services, preconception services, and infertility
services (see Figure 3a). The APN is directed to assess the woman's previous menses in
greater detail to determine if the woman may need intervention for non-pregnancy related
amenorrhea.

Literature about secondary amenorrhea states that the amenorrhea may not be
transient, and that the woman should be assessed when any one of four criteria are

positive: 1) the woman has not had a menses for three or more cycles, 2) the woman has

20
Wham

    
 
  

 

WW
Missed 2 3 cycles?
Missed 2 6 months?

Postpartum/nonlactating and missed 2 12 weeks?
Postinduced abortion and missed 2 8 weeks?

i I

No to ALL of the above questions? Yes to ANY of the above questions.

i l

( Does she desire pregnancy? ) Discgs Amenogheg:
L Initiate evaluation/services for
o

amenorrhea as appropriate to the

 

 

 

 

 

 

 

 

 

woman's needs.

 

 

Discuss Qontgception:
Initiate contraception as

_ ' Has she been trying to
appropriate to woman s conceive for > 1 year?
request.

i 1

..

Disc 5 reconce tio ervice
Initiate preconception services as
appropriate to her needs.

 

 

 

 

 

i

 

 

Discuss Infertility Servicgs

Initiate fertility services as
appropriate to her needs.

 

 

 

 

 

332m: The DeMann Algorithm: The Woman with a Negative Pregnancy Test

 

21

not menstruated for six or more months, 3) the woman is postpartum/nonlactating and
without menses for twelve or more weeks, 4) the woman is postinduced abortion and has
not had a period for eight or more weeks (Chikotas, 1995; Armstrong & South-Paul,
1996). The APN who determines that a woman fits any of the above criteria should
discuss amenorrhea with her and initiate evaluation to detemrine its cause.

If the woman does not fit any of the criteria, the APN progresses as though the
amenorrhea is transient. The APN assesses to determine if the woman is seeking
pregnancy. The woman who does not desire pregnancy should be counseled regarding
contraception, and contraception services should be provided as desired.

[fit is determined that the woman does desire pregnancy, the APN should assess
the length of time in which the woman has been trying to conceive. Infertility is a concern
when a woman has been unable to produce a viable pregnancy within one year of
unprotected intercourse (Pemoll, 1991). The woman who is having difficulty with
conception may benefit from infertility services and these should be discussed, offered and
initiated as appropriate to her needs.

The woman who is not infertile and is trying to conceive, should have
preconception services discussed and initiated as appropriate to the woman's request.
Preconception care includes a comprehensive assessment and attempts modification of
medical, psychological, and behavioral risk factors to help the woman actively prepare for
pregnancy. The goal is to provide the healthiest environment possible to the earliest
embryonic cells and reduce the chances of poor maternal and infant outcomes (Moos,
1989; Jack, et al., 1995).

The negative pregnancy test encounter can offer many opportunities to the APN to -
assess and intervene in the needs of a woman. While many APNs see the positive
pregnancy testing encounter as an opportunity for woman to assist with prenatal care,
women with negative tests may have other needs which should be assessed and

interventions should be offered.

22

| . l E . . E I
When the APN has performed a pregnancy test and the test result is positive,

assessment, intervention, and education should be offered (see Figure 3b). First, the
estimated date of confinement (due date) must be determined. This is done by using
Nagele's rule, i.e., subtract three from the month of the last normal menstrual period and
add seven to the first day that this menses started (Pemoll, 1991). For example, if the
LMP is 10/14/98, the EDC will be 7/21/99.

Next, the APN needs to assess the implications of the positive test result to the
woman: What is her reaction? Was she seeking pregnancy? Does she want to raise or
relinquish the child? Does she want an abortion? Is she undecided? (Hatcher, et al. 1994).
Once the woman's wishes have been determined, the APN should offer her supportive
interventions. The woman who wishes to continue the pregnancy to raise the child will
need prenatal care, as will the woman who wishes to relinquish the child for adoption. The
woman who wishes to relinquish, however, will also need initiation of adoption services
(Lauderdale & Boyle, 1994). The APN should discuss and initiate prenatal services and, if
the woman is relinquishing, the APN should discuss and initiate adoption services.

The woman who is undecided needs discussion and initiation of options counseling
as soon as possible (Brien, 1996). The APN should provide education on the importance
of a prompt decision to decrease poor outcomes. The woman may have questions about
What types of services and the types of personnel to expect at the agency of which she is
referred (Lauderdale & Boyle, 1994).

The woman seeking abortion will need referral and/or initiation of abortion
services as soon as possible (Slonim-Nevo, I991). The APN should educate her to the
importance of early termination. The APN should answer her questions or find a resource
Who can answer her questions.

Each woman with a positive test should be provided documentation of proof of a

positive test result; this can decrease the need for repeating the test when she is referred to

23

The Woman with a Positive Pregnancy Test

 

Assess;

 

Undecided?

[a . mm nu: I. 't .H\

Woman's reaction to positive test result.
Seeking pregnancy?
Raise the child?
Relinquish the child?
Terminate the pregnancy?

 

 

/

( Continuation of pregnancy )

i

Woman wishes
to raise child

i

 

 

 

 

 

[2' ii'
mm

 

 

 

i

 

 

Woman wishes
to relinqu‘uh child

 

 

 

 

 

I' |'
Educate re:

Ecourage prompt
decision to allow best
intervention, discuss
agency of referral.

 

 

 

 

 

l

J
\

 

( Termination of pregnarE

Ir

 

 

sealers

Educate re:

Need for prompt
intervention. Answer the
questions of woman
regarding procedure.

 

 

 

 

 

Review:
Gestational age

prenatal visit.

localized to one side.

vaginal bleeding.

1. Heavy bleeding
2. Heavy uterine cramping

 

Importance of early prenatal care
Discuss OTC medication use in pregnancy.
Discuss exercise. nutrition in pregnancy.
Advise avoidance of alcohol. tobacco. and other drugs.

Advise woman to take information regarding family health history to first

El II 'II 'I' I I III Ill
'1 .[. I i I . . . r.

l. Sudden intense pain or cramping in the lower abdomen which is usually

2. Irregular vaginal bleeding or spotting with abdominal pain.
3. Fainting or dizziness which lasts more than a few seconds with or without

3. Passage of blood clots or clumps of tissue.

WW

 

 

Eigure 3b: The DeMann Algorithm: The Woman with a Positive Pregnancy Test.

24

other agencies (Christmas, Pirani, Heagarty, & Schwartz, 1993). The APN should assess
her need for financial assistance no matter what her choice and refer/initiate services for
state assistance. The APN should provide education to the woman with a positive test
about the gestational age of the pregnancy (Hatcher, et al., 1994). The importance of
prenatal care should be discussed if the pregnancy is to be continued (Roberts, et al.,
1998). The woman should be educated to avoid over-the-counter medications unless her
APN is aware and confirms their use (Hatcher, et al., 1994). The woman should be
educated about exercise and nutritional information in pregnancy (Hatcher, et al., 1994).
She should be educated to avoid alcohol, tobacco, and other drugs (Pemoll, 1991). The
APN needs to instruct her on the necessary family and medical history information she will
need to provide when seeking prenatal care (Pemoll, 1991). Every woman with a positive
test should be educated about the signs/symptoms of ectOpic pregnancy and miscarriage
(Hatcher, et al., 1994). Finally, the woman should be allowed to ask questions of the APN
who should take the time to answer them or refer her to someone who can (Pemoll,
1991).

The pregnancy test encounter in which a woman is not using contraception is a
complex encounter, but when contraceptive methods are considered, the APN must
consider still more data. The following sections will address assessment and interventions
which should occur when a woman is using: oral contraceptives (OCs), Depo-Provera
(DMPA), Norplant, intrauterine devices (IUDs), or has had a tubal ligation.

II 1!! , I .

When the APN has determined that the woman is using oral contraceptives (OCs),
the algorithm directs the APN to determine if the woman has missed a menses (see Figure
30). If she has not, the APN is directed to determine if she is concerned about missed or
late OCs, or a recent sexual experience. If she is not concerned about these, the APN is
directed to address her concerns, and to provide information about the effectiveness of

OCs, including when to return to the health setting if amenorrhea occurs (Hatcher, et al.,

 

 

 

K
m it“ m “In in m .3“:
Is she concerned re. unnerving 0C5 or
arm sexual encounter

i
i

 

 

W
mm; W
Discussfiruuate emergent) Bialwfllfli 0‘ 0C5 IN

 

contraception as needed

 

 

when to return to clinic it
tinned menses occurs

 

 

 

 

  
    

 

 

[Am [3; Side ellects ol
OCs. Assess uusucnon
Vim item: I» she
slashed nth her method“

 

 

 

vi

i

i i

Mum
Wetdtnten‘m u

 

   
 

 

 

 

 

mm

t.e . brew tenderness. needcd
taugtic. Il'llil’) tre~

quency. Warming,

nipple sensiuvity?

 

 

 

BBT. clla‘tn'emu
or ()0. back-up
methods return to
other It z missed
arme- or 331’ :-

Mam
Arman of tests. what
to return to clinic. back-

upmahodsqroperuu.
i

 

 

 

m

Prom use 01 00. back-up
mm. side eflecu.
checking BBT Am

 

98f Samba! nth
sanitation with tin-thou. “and.
is the satisfied nth ' '

 

 

m

Accuracy of test. and when
to return to clinic in
mun; [Menu/initiate
[recruit-epoch )t'fliilf)

 

 

 

 

 

 

 

 

 

figure 3c. The DeMann Algorithm. The Woman Using Oral Contraceptives.

 

26

1994). If the woman is concerned about missed or late OCs, or a recent sexual experience,
the APN needs to assess when the OCs were missed or taken late in respect to the sexual
experience of concern; the APN should consider the woman's candidacy for emergency
contraception. The woman who fits the criteria for emergency contraception, should be
offered emergency contraceptive services (Ward-Morgan & Deneris, 1997).

If she has missed a menses, the APN should assess if she has had any vaginal
spotting or brown vaginal discharge while taking the nonhormonal reminder pills, since
these are considered a withdrawal bleed when using OCs (Hatchet, et al., 1994). For the
woman who has had spotting or brown discharge, the APN should educate the woman
regarding the menstrual changes which can occur (Hatcher, et al. 1994). The woman
should also be assessed to determine if she is satisfied with her method, since satisfaction
is directly related to proper and continued use (Rosenberg, Waugh, & Long, 1995). The
woman who is unsatisfied should be referred for contraceptive services to decrease her
chances of discontinuation and unintended pregnancy (Hatcher, et al., 1994). The woman
who is satisfied with her method may benefit from reassurance, and education about when
to return to the clinic for testing (Hatcher, et al., 1994). The APN should intervene as
appropriate to the woman's needs.

The woman who has not had any bleeding or spotting should be assessed to
determine if she has been using her pills correctly, i.e., taking them daily and at
approximately the same time; is using medications which can alter the effectiveness of
OCs, i.e., gastrointestinal, antiseizure, or antibiotic medications; or has had
vomiting/diarrhea which can also alter efiectiveness (Hatcher, et al., 1994). The woman
who has not been using the OCs correctly is at an increased risk of pregnancy, and should
be evaluated for timing of risk behavior to determine if testing will be accurate, and
assessed for the possible use of emergency contraception if pregnancy is not desired
(Ward-Morgan & Deneris, 1997). The APN who finds that the recent sexual experience

was more than 14 days prior to the encounter, should perform a pregnancy test. If the test

27

result is positive, the APN is referred to Figure 3b, The DeMann Algorithm: The Woman
with a Positive Pregnancy Test. If negative, the APN educates the woman about the
proper use of OCs, the use of back-up methods when she is using GI, antiseizure, or
antibiotic medications, has had vomiting or diarrhea, or has missed OCs or taken several
late. The APN should educate the woman to check her basal body temperature (BBT) as
indication of ovulation and pregnancy (Hatcher, et al., 1994). A BBT of less than 98.0 F
means she has not ovulated; if she has BBTs greater than 98.0F, she should be educated to
return to the ofiice for testing (Hatcher, et al., 1994). The APN also needs to assess if the
woman is satisfied with her method, offer education and reassurance to the woman who is
satisfied, and initiate contraceptive services if she is not.

Ifthe sexual experience was less than fourteen days prior to the encounter, the
APN needs to determine if the recent sexual experience was less than or equal to seven
days before the encounter, since emergency contraception may be an option (W ard-
Morgan & Deneris, 1997). If the sexual experience was more than seven days before the
encounter, the APN is directed to educate the woman on the accuracy of tests, when to
return to the health setting for an accurate test, the use of a back-up method for the rest of
the cycle, and proper use of the OCs (Pemoll, 1991', Hatcher, et al., 1994).

The APN who determines that the sexual experience was within the last seven days
needs to assess whether the woman is seeking pregnancy. When the woman is not seeking
pregnancy, the APN discusses emergency contraception and initiates services if the
woman desires, and discusses contraceptives and initiates services if the woman wants to
change her method (Hatcher, et al., 1994, Ward-Morgan & Deneris, 1997). The woman
who desires pregnancy, yet whose sexual experience was within fourteen days of the
encounter, should be educated as to when to return to the clinic for accurate testing, and
preconception services should be discussed and initiated appropriate to the woman's needs

(Hatcher, et al., 1994).

28

The woman who has not missed pills, taken pills late, used antibiotics, antiseizure
or G1 medications, and has not had vomiting or diarrhea, should be assessed for
signs/symptoms (S/S) of pregnancy. Hatcher, et al. (1994) recommended a pregnancy test
if two consecutive cycles have been missed unless S/S of pregnancy are present. If they
are present, the APN is directed to perform a pregnancy test. The APN is again directed to
Figure 3b, The DeMann Algorithm: The Woman with a Positive Pregnancy Test if the test
is positive. If negative, the APN needs to offer reassurance, and educate regarding proper
use of OCs, back-up methods, side effects of OCs, and checking BBTs as previously
discussed. The APN should also assess the woman's satisfaction with her method
(Hatcher, et al., 1994). The woman who is not satisfied should have available
contraceptive services discussed and selecied as appropriate to her needs (Rosenberg,
Waugh, & Long, 1995). The woman who is satisfied should receive education and
reassurance as needed.

For the woman who has not had S/S of pregnancy and has not missed two or more
consecutive cycles, reassurance about the effectiveness of OCs should be offered. She
should be educated to return to the office if she has two consecutive missed menses
(Hatcher, et al., 1994). The APN also needs to educate her to check her basal body
temperature (BBT) as an indication of ovulation and pregnancy (this procedure was
discussed earlier in this section on page 27) (Hatcher, et al., 1994). Furthermore, the
woman should be educated to use a back-up or interim method when she has been using
medication that decreases the effectiveness, has vomiting or diarrhea, has missed pills or
taken pills late (Hatcher, et al., 1994). Finally, the woman should be assessed for
satisfaction with her method (Rosenberg, Waugh, & Long, 1995). If she is not satisfied
initiation of contraceptive services should occur. If the woman is satisfied, the APN should

educate and intervene as needed.

29
Iheflcmmufingmfimma

Depo-Provera (DMPA), a progestin only injection, is yet another method of
contraception which can cause amenorrhea and concern from the user regarding
pregnancy status (Hatcher, et al., 1994). Figure 3d, The DeMann Algorithm: The Woman
Using Depo-Provera, applies specifically to the woman using DMPA who presents for a
pregnancy test (see Figure 3d). .

The woman using Depo-Provera (DMPA) should be assessed for a missed menses.
If she is not late, the LMP should be assessed to determine if it is "abnormal" for her. If
the menses was "normal", the woman should be assessed to determine why she believes
she needs a test, and education should be offered which is appmpriate to her needs
(Hatcher, et al., 1994).

If the woman has missed her menses or her menses is "abnormal", the APN should
determine if she has missed a dose of DMPA, i.e., has not received a dose in more than
fourteen weeks. If she is not late for her shot, and/or she has had changes in her cycle, the
APN is directed to assess for S/ S of pregnancy (Hatcher, et al., 1994). The woman who is
not having S/ S of pregnancy should be offered a test at the first missed menses (Hatcher,
et al., 1994). The woman who is having S/ S of pregnancy should have a test performed
(Hatcher, et al., 1994). The APN is directed to Figure 3b, The DeMann Algorithm: The
Woman with a Positive Pregnancy Test, when a test is positive. For a negative test, the
APN should offer education about the side effects of DMPA, and assess the woman's
satisfaction with the method. If unsatisfied the APN should discuss and offer contraceptive
services to decrease discontinuation, and risk of unintended pregnancy (Rosenberg,
Waugh, & Long, 1995). If the woman is satisfied with her method, the APN should
educate and intervene as needed.

When a woman is late for her DMPA, another direction is advised. The risk
behavior should be assessed for timing. If it was less than fourteen weeks afier her last

shot, she was protected, and she should be educated about DMPA side effects, and the

+

    
    
   
     
 

Date; Is the late? Timing as expected?
Length as expected? Amour“ of flow as expected"
Was menses ”normal?‘

./ i

 

 

 

 

 

 

 

 

 

Fm is "normal"! LNo inane: is not normal—l

i
WI I I I. [lsdateolhslinjection>ldweeksfij
W i i

 

 

 

 

after tut injection?

Mamas);
Was rental encounter of mm > H m5

 

i
...........
{7

Educate re: DMPA
side effects. Duel she
desire pregnancy?

i

I
w

   

     
   
   

  

Eficcusems of
DMPA. otter test
with lst occurrence

it
i i
i

Does she «in
pun-no?

   
  
 

Side cltects ol

DMPA Assess

 

 

 

 

 

 

satisfied with .
method? ‘
n. [I . I

t - "‘ W W;
' B Mdcd .
‘ PM TS! Test accuracy Con \c

emergency semces
‘ W
“mm l i hen to return to

 

 

 

 

 

 

 

 

 

 

clinic lot testing
m accuracy of
tests and when to

return for testing

 

 

 

 

W Discuss possmlc IS
Contraceptive W months to CDMCIVC.
scrvrces as needed Does she desire

 

 

 

 

 

 

 

pre gnancy ?

 

 

Comm-rpm! W
m I" I . :‘ _.

 

 

 

 

 

M The DeMann Algorithm: The Woman Using Depo-Provera.

31

APN should determine if she is seeking pregnancy (Hatcher, et al., 1994). If the woman
does not desire pregnancy, the APN should assess if she is satisfied with her method
(Hatcher, et al., 1994). If the woman is not satisfied, the APN should discuss/initiate
contraception services as needed (Hatcher, et al., 1994). If the woman is satisfied, the
APN should educate/intervene as needed (Hatcher, et al., 1994).

The woman who is late for her injection, is at risk for pregnancy, and should be
assessed to determine if the sexual experience was less than seven days before the
pregnancy test encounter. If the sexual experience was less than seven days before the
encounter, the woman should receive discussion and/or initiation of emergency
contraception as appropriate. If the woman desires pregnancy, she should be educated
regarding the accuracy of tests, and when to return to clinic for testing. She should also be
educated regarding the possibility that conception could take up to 18 months to occur
after her last DMPA dose (Hatcher, et al., 1994). If emergency contraception is not
possible because her risk behavior was more than seven days before the encounter, the
APN should assess if the sexual experience was more than 14 days prior to the encounter;
if it was not, the woman should be educated about test accuracy, and when to return to
the office for a test (Hatcher, et al., 1994). If the risk behavior was more than fourteen
days before encounter, a test should be run (Pemoll, I991). The APN is referred to Figure
3b, The DeMann Algorithm: The Woman with a Positive Pregnancy Test, if the test is
positive. If the test is negative, the APN is directed to discuss post-DMPA amenorrhea
and assess if pregnancy is desiredt(Hatcher, et al., 1994). If the woman does not desire
pregnancy, the APN should discuss and initiate contraceptive services. If the woman
desires pregnancy, education on return to fertility after DMPA should be given and
preconception services should be discussed and initiated as needed (Hatcher, et al., 1994).
The woman who is late for her shot because she is seeking pregnancy should be educated
to the possibility that conception can take up to 18 months after the last dose (Hatcher, et
al., 1994).

32
Iheflomanllsinghlcrplam

Norplant is another progestin-only contraceptive method. It consists of six
implants of levonorgestrel inserted under the skin (Hatcher, et al., 1994). Unlike DMPA
which causes amenorrhea afier a nine months to one year use of DMPA, Norplant causes
most amenorrhea within the first year of insertion (Hatcher, et al., 1994). The APN
assessing a woman using Norplant must consider the side effects of Norplant, the cost of
the Norplant, and the cost of insertion and removal when intervening with the woman with
Norplant (Hatcher, et al., 1994). Hatcher, et al., discussed that education is the key to
intervening with women using Norplant and DMPA that are having changes in their
menstrual cycle.

First, the APN should assess the LMP, i.e., date, timing of cycle, length of flow,
and amount of flow (see Figure 3e). If the woman's menses is not late, or has not changed,
the APN is directed to assess the reason the woman believes she needs a test and to
educate and intervene as appropriate to her needs. If the woman's flow has changed, or
she has missed a menses, the APN is directed to assess whether she has had any menses
since insertion (Hatcher, et al., 1994).

The woman who has been having periods since insertion should be assessed for
signs and symptoms (S/ S) of pregnancy (Hatchet, et al., 1994). If the woman is having S/ S
of pregnancy and she has missed a menses, a pregnancy test should be performed
(Hatcher, et al., 1994). The APN is referred to Figure 3b, The DeMann Algorithm: The
Woman with a Positive Pregnancy Test, if the test is positive. If the test is negative, the
woman should be educated about the side effects of Norplant, the effectiveness of the
method should be reviewed, and the APN should assess her satisfaction with the method
(Hatcher, et al., 1994). Hatcher, et al., suggest the APN discuss the importance of
education/reassurance since menstrual changes with Norplant tend to self correct after one
year of use, and Norplant is a very effective yet costly method if not kept for the five year

effectiveness period. If the woman is not satisfied with her method the APN should

 

Date: Is she late?
Timing as expected?

Length as expected?

Amount of flow as expecred?
Was menses ”normal?"

 

 

 

 

I Yes menses was "not-mm I No menses was not "normal." I

i v

 

 

 

W v Has she had a menses since Insertion?
Educate/intervene as needed. *

 

 

 

i
Yes
i

Was Norplant inserted < 6

weeks before the visit? Was
she at risk for pregnancy at
the time of insertion?

 

V

 

 

 
 
  

Yes - ma Breast Tenderness
* Fatigue
Nausea/Vomiting

 

Urinary Frequency

 

 

@rm Pregnancy TesD
f i t i
iv i
' Gm this her 1st episode )
of amenorrhea?

i
\ v
y*/ Perform Pregnancy®

t iv
Side effecrs of Norris?
vb

 

 

 

 

 

 
  
   

 

Effectiveness

Satisfied with method?
W

 

 

 

i
i
W W

Inserted . .
appmpriate to woman 5 needs

 

 

 

 

 

 

Em The Dean Algorithm: The Woman Using Norplant.

34

discuss and/or initiate contraception services appropriate to the woman's needs (Hatcher,
et al., 1994). If the woman is satisfied, education and intervention should be offered
appropriately (Hatcher, et al., 1994).

The woman who has had no S/S of pregnancy with the amenorrhea should be
assessed to determine if this is her first episode of amenorrhea. Hatcher, et al., (1994)
recommend a test for the first episode of amenorrhea, and the APN is directed to perform
a pregnancy test as previously discussed. If this is not the woman's first episode of
amenorrhea, and she does not have S/S of pregnancy, the APN needs to educate about the
side efl‘ects of Norplant, the effectiveness of the method, and to discuss and assess her
satisfaction with the method (Hatcher, et al., 1994). The APN who finds an unsatisfied
Norplant user must discuss Norplant and discuss/initiate contraceptive services
appropriate to the woman's needs (Hatcher, et al., 1994). If the woman is satisfied, the
APN should educate and intervene according to the woman's needs (Hatcher, et al.,

1994).

The woman who has had no menses since insertion should be assessed for insertion
date, and risk of pregnancy at the time of insertion (Hatcher, et al., 1994). If the APN
finds that the Norplant was not inserted within seven days of the LMP and the woman did
not use an interim method for the first two weeks, the woman may be at risk for
pregnancy, and the APN should perform a pregnancy test. The APN is directed to Figure
3b, The DeMann Algorithm: The Woman with a Positive Pregnancy Test, if the test is
positive. If the test is negative, the APN is directed to educate about side effects of
Norplant, it's effectiveness, and to discuss and assess the woman's satisfaction with the
method. If unsatisfied, the APN is directed to fiirther discuss Norplant, and to discuss and
initiate contraceptive services as appmpriate to her needs (Hatcher, et al., 1994). The
woman who is satisfied, should receive interventions appropriate to the woman‘s needs.

When the Norplant has not been inserted within the last six weeks, there is not a

risk for pregnancy at the time of insertion and the woman has amenorrhea, the APN

35

should assess for S/S of pregnancy and complete the algorithm as previously discussed for
the woman who has missed a menses after having had menses with Norplant (Hatcher, et
al., 1994).
Iheflcmanllsinganlllfl

The IUD user who presents for pregnancy testing must be assessed carefully.
While the IUD is another very effective method of contraception, the method is not 100%
effective when in place, and an IUD may be expelled from the uterus (Hatchet, et al.,
1994). Two-thirds of the IUD-related pregnancies occur with the IUD properly in place.
Thus, the woman who becomes pregnant with an IUD has a greater risk of ectopic
pregnancy, and an increased risk of miscarriage and should contact her family planning
APN when she misses a menses (Hatcher, et al., 1994). Another issue the APN must
consider is that the woman using an IUD who finds herself pregnant was probably not
seeking pregnancy, and she may be highly emotional. Furthermore, because some of the
IUDs can be left in place for 10 years, it is possible that the woman using an IUD may
have it in place when perimenopausal symptoms begin, and assessment will be necessary
to assess if this is indeed the case (Hatcher, et al., 1994).

The APN who encounters the woman using an IUD should first assess her menses
(see Figure 30. The APN should assess the date of the LMP, the timing of cycle, and if
the woman has had changes in length or amount of flow to determine if the menses was
"normal" for the woman. If her menses is "normal" the APN must assess why she believes
she needs a test, and provide education and intervention as needed (Hatcher, et al., 1994).

The woman whose menses is late or "abnormal" should be tested for pregnancy
(Hatcher, et al., 1994). The APN is referred to Figure 3b, The DeMann Algorithm: The
Woman with a Positive Pregnancy Test, if the test is positive and she should be educated
regarding the increased risk of miscarriage and ectopic pregnancy (Hatcher, et al., 1994).
If the test is negative, an assessment should take place to assess for other causes of

secondary amenorrhea (Chikotas, 1995; Armstrong & South-Paul, 1996). The APN

 

Asse ess LMP;
Date:

   
 

 

Is she late?
Timing as expected?

Length as expected?

Amount of flow as expected?
Was menses "normal?"

 

v

Yes menses is 'normal."

i

 

 

 

 

 

s w l' v s
gggds a test?
c t rv nea n e .

 

 

 

 

No menses is not "normal."

i

Perform Pregnancy Test )

i
i

 

 

 

 

 

 

 

A§S€SS QIEVIOQS menses

Missed > 3 cycles?
Missed > 6 months?

Postpartum/nonlactating missed > 12 weeks?
Postinduced abortion missed > 8 weeks?

vlv

Not to ALL of the
above questions.

i

Educate:

Effectiveness of IUD
Assess client age, could she
be perimenopausal? Is she
having hot flushes or night
sweats?

t t
i v

 

 

 

 

 

 

SEEM
Educate:

Increased risk of
miscarriage and
ectopic pregnancy.

 

 

 

 

 

Yes to ANY of the above
questions.

 

 

i

 

 

Discuss/Initiate
Amenoghea Services

 

 

 

 

amptgms. Educate m: amen r
WM t er

 

W Discuss ransi ntc uses

 

vider

when

 

 

Warren:

CE oth

 

 

 

Figure 3f: The DeMann Algorithm: The Woman Using an IUD

37

should ask several questions which can determine if the amenorrhea is not transient. These
questions were identified in relation to Figure 3a, The DeMann Algorithm: The Primary
Assessment of the Woman Seeking Pregnancy Testing, (Chikotas, 1995; Armstrong &
South—Paul, 1996). If the woman answers yes to any of the questions assessing previous
menses, the APN should discuss and initiate evaluation for secondary amenorrhea
(Chikotas, 1995; Armstrong & South-Paul, 1996).

When the woman answers no to all of the questions assessing for secondary
amenorrhea, the APN is directed to educate about the effectiveness of the IUD and to
assess the woman's age to determine if the woman could be perimenopausal; i.e., does she
have hot flashes or night sweats (Pemoll, 1991). The woman who is having S/S of the
perimenopausal period should be educated about menstrual changes and vasomotor
symptoms. Hormone replacement therapy and other therapies to decrease symptoms
should be discussed (Pemoll, 1991). The woman who is not having perimenopausal
symptoms can be educated about transient causes of amenorrhea and when to call the
APN with concerns (Pemoll, 1991; Chikotas, 1995; Armstrong & South-Paul, 1996).

I] III 'lIllI' .

The woman who is seeking pregnancy testing and has had a tubal ligation must be
carefully assessed because of the increased risk of ectopic pregnancy (Hatcher, et al.,
1994). Tubal ligation has a failure rate of only .4% but the woman who becomes pregnant
has up to a 73% increase in her risk of ect0pic pregnancy (Hatcher, et al., 1994). Tubal
ligation is a permanent method of contraception, and the woman will go into menopause
with this method (Hatcher, et al., 1994). The APN must take this into consideration when
presented with a woman requesting a pregnancy test.

The algorithm directs the APN to assess the woman's LMP to determine if she is
late for her menses and to determine "normalcy" of menses (see Figure 3g) (Hatcher, et

al., 1994). lfmenses is not late, and is "normal" for the woman, the APN assesses why the

38

woman believes she needs a pregnancy test and should educate/intervene as appropriate to
her needs (Hatcher, et al., 1994).

The woman who has missed her menses or has had an "abnormal" cycle should be
assessed for S/S of pregnancy. If S/S of pregnancy are present, a test should be performed
(Hatcher, et al., 1994). If the test is positive, the APN is referred to Figure 3b, The
DeMann Algorithm: The Woman with a Positive Pregnancy Test, and education should be
given on increased risk of ectopic pregnancy (Hatchet, et al., 1994). If the pregnancy test
is negative, the woman's previous menstrual history should be assessed to determine if
another cause of secondary amenorrhea should be explored (Chikotas, 1995; Armstrong &
South-Paul, 1996).

If the APN assesses that other causes may be present, the APN should discuss and
initiate evaluation for amenorrhea appropriate to the woman's needs (Chikotas, 1995;
Armstrong & South-Paul, 1996). If the APN assesses that the amenorrhea may be
transient, the woman should be educated about the transient causes, effectiveness of tubal
ligation, and the woman's age should be assessed to determine if the woman could be
perimenopausal (Chikotas, 1995; Armstrong & South-Paul, 1996). If she could be
perimenopausal, the APN should discuss the S/ S of perimenopausal period, and educate as
needed regarding hormone replacement and other therapies (Pemoll, 1991). If she could
not be perimenopausal, the APN should educate/intervene as appropriate to her needs.

The woman who has missed a menses and is not having S/S of pregnancy should
also be assessed for causes of amenorrhea other than pregnancy as discussed in the above
paragraph. If the woman answers yes to the questions assessing for secondary
amenorrhea, a pregnancy test should be ordered. (Chikotas, 1995; Armstrong & South-
Paul, 1996). If the test is positive, the APN refers to Figure 3b, The DeMann Algorithm,
The Woman with a Positive Pregnancy Test. If the test is negative, the APN should

discuss/initiate services for amenorrhea (Chikotas, 1995; Armstrong & South-Paul, 1996).

39

W

l

W
Dare: __ Isshetue‘.’ “mgnapected?

Lengthesexpected? Amendflowas
expected? Wesmes'nomnl?‘

l
Wale

min:
W

 

 

 

 

 

Missed23cyda?

Manama»?
Poetpermnmmmngm'uedznweeks?
WWWszeks?

4 l

 

 

 

 

 

Yes to ANY of No to ALL
the above of the above
question mien--

 

 

 

 

Perfor- Pregnancy
Test

l
EE]
l

"‘

l
l

 

Perform My
mum
, am
Semen:

 

 

 

m
l

'V
.____E._

 

W
Educate re:
unused risk of
ectopic pregnancy

 

 

 

 

 

 

 

 

movie turn-M;

 

 

 

 

No to ALL
of the above

 

 

 

   
  

 

 

 

 

Transient causes of mtenonhea. eflecuveness
ot tubal ligation. Assess client age. count she
be penmempausal"

 

 

 

 

 

 

 

 

F. igure 32, The DeMann Algorithm: The Woman with a Tubal Ligation.

 

 

40

If the woman does not answer yes to any of the questions, secondary amenorrhea
should be assessed to determine if this is her first occurrence of amenorrhea. The woman
who has had her first episode of amenorrhea should have a pregnancytest performed
(Hatcher, et al., 1994). If the test is positive, the APN is referred to Figure 3b, The
Woman with a Positive Pregnancy Test, and the APN should educate about the increased
risk of ectopic pregnancy (Hatcher, et al., 1994). If the test result is negative, the APN
should educate regarding transient causes of amenorrhea, and the effectiveness of tubal
ligation. The APN should also assess the client's age, and S/S of perimenopause (Hatcher,
et al., 1994). If perimenopausal symptoms are present, the APN should discuss the S/S of
perimenopausal period, hormone replacement therapy and other therapies available as
desired by the woman (Hatcher, et al., 1994).

Implications

Implementation of the proposed algorithm offers a variety of opportunities for
APNs and health agencies which could enhance the care of the woman seeking a
pregnancy test. Implications related to its use in the areas of research, education, and
practice are discussed.

1] E I l ! . | I E .

Implementation of the DeMann Algorithm into practice requires a plan. One
possible plan is to obtain organizational administrative support for the algorithm; once
administrative support is obtained, the algorithm can be shared with others in the agency.
To obtain administrative support, it is necessary to show the benefits the algorithm holds
for the agency. It may be helpfiil to discuss the potential for lower expenditures, since
fewer tests are likely to be ordered unnecessarily or inappropriately if the algorithm is
followed. Also, administrators might appreciate that the use of the algorithm could initiate
preconception, family planning, infertility, and other services which could initiate
additional revenue for the agency. Contracting with the agency for a trial period and

developing tools to evaluate the effectiveness of the algorithm will be necessary to fully

41

gain administrative support. To evaluate the algorithm, it will be necessary to collect data,
e.g., the number of encounters which resulted for the agency when client needs were
identified, the number of pregnancy tests performed, and the various outcomes of the
pregnancy testing encounters. These could occur through chart review, and/or patient
survey.

Another consideration in implementing the algorithm is that of the advantages and
disadvantages of the use of algorithms in the health care setting could be examined. A
significant advantage to the use of an algorithm is that it standardizes the care offered to
clients. An algorithm also provides a visual representation which may assist APNs with
less expertise to include all necessary entities of the pregnancy test encounter, and enhance
client outcomes. Another advantage is that algorithm use has the potential to decrease the
cost of services to the organization while increasing the quality of care. Algorithms also
offer management strategies which could benefit both APNs and the women seeking care,
however, disadvantages to algorithms also exist. Some APNs believe that an algorithm
takes away fiom the individualized care that the APN has to ofl‘er; other APNs believe that
an algorithm is an elementary tool, much like following a cookbook.

Despite the advantages and disadvantages, the algorithm will not be utilized by
APNs or other HCPs if the information is not disseminated to them appropriately. The
algorithm could be presented at conferences around the country or in APN education
programs. Using conferences and college courses, the algorithm would reach APNs in a
more formal educational format. Unfortunately, conferences and course offerings would
not reach large numbers of APNs, would be limited only to the disciplines the conference
attracted and would involve the cost of transportation, lodging, and lost work time.

Another means of dissemination of The DeMann Algorithm could be to publish it
in nursing journals. The advantage of publishing the algorithm would be that it would

reach many APNs of many disciplines. Two journals which could be appropriate for

42

publishing the DeMann algorithm are the Mmmammmman
Nursing and Eatmmfiamhlmflammnnet
IheDeMannAlgodflmmdfieseamh

The algorithm offers many opportunities for research. First, APNs' attitudes about
using the algorithm and their satisfaction with the format of the pr0posed algorithm could
be evaluated. The knowledge of APNs about the complexities of pregnancy testing and
their attitudes about the algorithm as a guide to practice could also be evaluated.

Second, the number of women who present with needs for education, prenatal
care, preconception care, secondary amenorrhea, contraception, infertility and options
counseling could be determined. Along with this, researchers could look at the length of
time it takes women to obtain services for prenatal care, family planning, infertility,
options counseling, amenorrhea, preconception care. and adoption when referred and the
type and frequency of referrals made.

Third, a study could be done to detennine the level of satisfaction of the woman
when the APN uses the algorithm at the pregnancy testing encounter. This study might
also assess the length of time necessary for the APN to use the algorithm as proposed.

Fourth, a study could be implemented to determine if the algorithm actually does
identify the needs of women. This study might also assess if needs identification
demonstrated improved education for women, an increase in the women’s ability to receive
earlier prenatal care, the adequacy and the appropriateness of preconception services
offered, a reduction in the number of unintended pregnancies, an increase in the use of
contraception, the number and length of time it takes women with infertility to seek and
receive services, and the number of women who are referred and/or receive options
counseling.

Fifth, research could also look specifically at the number of women who present
within seven days of the sexual encounter, and the attitudes/acceptance of these women

for emergency contraceptive services. Research could also assess the number and attitudes

43

of women who want a pregnancy test performed but are declined pregnancy testing and
advised to return for a pregnancy test at a later date, which can occur due the time it takes
for hCG to be detected in either a serum or urine sample.

Sixth, the number of tests performed unnecessarily and inappropriately could be
studied. This would give a better indication of the dollars which could be saved through
the implementation of the algorithm.

Finally, the extent to which support staff are ordering tests, the reasons this occurs,
the educational preparation of these staff members, and the satisfaction of women who
have pregnancy testing performed by support staff could be examined. The attitudes of
APNs, PAs, and physicians and health agencies in regards to support staff performing
pregnancy testing can be assessed. Finally, research could take place which compares the
support staff to the APN in regards to the needs identified and the interventions offered at
the time of the pregnancy testing encounter.

II D l l g l . 1 l E l .

This project and the algorithm suggest multiple implications for education.
Education can occur for both the APNs, for companies who sell over-the—counter
pregnancy tests and for the clients who are seen. Colleges and certification programs,
which prepare APNs for practice must recognize the complexity of the pregnancy testing
encounter and offer curriculums which educate the APN appropriately. In addition,
companies which sell over-the-counter pregnancy tests must be knowledgeable about the
many implications for women at the time of pregnancy testing. Every pregnancy test
package insert should include information regarding where to seek prenatal services, when
to consult a health care provider, and information on other causes of amenorrhea.

Health settings which allow support staff who have contact with clients at the time
of the pregnancy testing encounter must be educated to understand the opportunities

Pregnancy testing offers both women and their health care agencies. Education could

44

focus on more thorough assessment of the woman to determine the need for
preconception care, family planning services and amenorrhea services.
IheDeMannAngfithmjndhamm

There are many implications for APNs who follow the DeMann Algorithm. First,
the APN must be aware of his/her feelings regarding contraception, pre and postcoitally.
Since some methods of contraception are viewed negatively by some APNs, the APN
must be able to recognize his/her ability to offer comprehensive services and may need to
refer the woman to another APN if he/she is unable to offer the woman the freedom to
choose methods which best suit her needs. Second, the APN must be aware of his/her
feelings regarding adoption and abortion. The APN who can not be objective should
refrain from caring for women seeking pregnancy testing. The pregnancy testing encounter
should be performed by a APN who is devoted to women's health and wants to deliver
only the highest quality of care (Hatcher, et al., 1994).

There are implications for APNs to fiilfill many roles within their practice. As an
assessor the APN must ask questions and listen to the cheat in order to assess her needs.
Application of this algorithm provides many opportunities for the APN to increase client
knowledge in the areas of women's health care by fulfilling the role of an educator. As a
collaborator the APN who follows the algorithm may refer the client to a reproductive
endocrinologist, an obstetrician/gynecologist (OB/GYN), an abortion clinic, or an
adoption agency. This role requires the exchange of information, and participation in the
management of the overall health care of the woman with other members of the health
care team. The APN may also act as a case manager who monitors the client's progress
through the referrals. The APN may act as a counselor, as well. It may be necessary to
provide support to the client who has an unintended pregnancy and is overwhelmed with a
positive test result. If a woman is seeking a test before the test could reveal an accurate
result will act as a planner in scheduling a date to return for testing. Finally, the APN who

uses the algorithm can act as a role model to other health care providers, e.g., in peer

45

review, the APN using the algorithm can evaluate other APNs pregnancy testing
encounters, and offer the algorithm as a tool to APNs who are not offering comprehensive
care.

Next, there are irnplications for the primary care setting in which the algorithm is
used. The primary care setting will need to have orientation/inservice procedures in place
to educate APNs in the appropriate use of the algorithm. The setting will also need to
determine the services which it is able to provide and those which require referral to other
services in the area in order to meet the needs of the women appropriately.

While this project focuses on the APN as the personnel to use the algorithm, the
algorithm could also be utilized by physician assistant, and physician providers.
Furthermore, in health settings in which there is a APN shortage, settings might consider
modifying the algorithm in a fashion which would allow support staff, i.e., medical
assistants (MAS), licensed practical nurses (LPNs), registered nurses (RNs), to use the
algorithm to assess whether a test should be ordered and determine when the woman
would need to see an APN for advanced assessment and intervention. Some agencies,
such as Planned Parenthood settings, orient their support staff to properly assess last
menstrual periods, contraception use, desire for pregnancy, and a risk of pregnancy.
Support staff, with education could firlfill these portions of the DeMann Algorithm.
Registered nurses, who have had course work which is specific to obstetrics/gynecology
could perform the assessment and make referrals for intervention as discussed in the
algorithm.

The primary care setting will need to determine if any of the services included in
the DeMann Algorithm conflict with funding sources or the philosophy of the
organization. Agencies such as school-based health centers in Michigan must refer a
woman to an agency which offers options counseling and can not discuss abortion or refer
a woman directly for abortion services or grant funds will be forfeited (Minimum Program

Requirements of School-Based Health Centers, 1997). The primary care settings in which

46

there are conflicts must modify the algorithm and/or find referral services which meet the
needs of women. Finally, there are opportunities for health settings to gain revenue by
identifying and intervening when needs other than that of the chief concern, the pregnancy
test, are identified, e.g., preconception services, amenorrhea services, and contraception
services.

Conclusion

There are many opportunities to intervene in the lives of women at the time of the
pregnancy testing encounter. While the pregnancy testing encounter is often viewed as
simply performing a pregnancy test, it should be viewed as a complex contact which
requires in-depth knowledge, assessment and critical thinking in order to best serve the
needs of women seeking a pregnancy test.

Starfield's framework has provided an appropriate approach, i.e., the structure,
process, and outcome variables, for evaluating services/care provided in the primary care
setting. The proposed DeMann Algorithm represents a process which the APN can follow
when providing services to the woman seeking a pregnancy test. Just as algorithms have
become a part of health practices and have improved the quality, the consistency of service
and the cost of care; the proposed algorithm for the pregnancy testing encounter has the
potential to enhance positive outcomes for women and their children and may reduce
fi'agmentation of care.

Health care agencies need to review their practices related to the provision of
pregnancy tests. Agencies who adopt the DeMann Algorithm should be in a more positive

position to promote comprehensive services at a crucial time in a woman's life.

APPENDIX

MANAGEMENT OF THE PREGNANCY TESTING ENCOUNTER:
THE DEMANN ALGORITHM

By

Donna J. DeMann

There are many opportunities to intervene in the lives of women at the time of the
pregnancy testing encounter. Interventions could include one or more of the following;
preconception care, infertility services, pregnancy Options counseling, evaluation for
amenorrhea, prenatal care, or family planning. While the pregnancy testing encounter is
often viewed as simply a time to perform a pregnancy test, it should be viewed as a
complex contact which requires in-depth knowledge, assessment and critical thinking in
order to best serve the needs of the woman seeking a pregnancy test. This algorithm was
developed to guide the health care provider (HCP), specifically the advanced practice
nurse (APN) who cares for the woman seeking a pregnancy test. The DeMann Algorithm
consists of a primary algorithm plus a series of secondary algorithms, which will guide the
APN to determine the needs and interventions appropriate to each woman seek a
pregnancy test. The primary algorithm (Figure 3-The DeMann Algorithm: The Primary
Assessment of the Woman Seeking Pregnancy Testing) reflects the overall picture of the
woman's request for pregnancy testing. The primary algorithm directs the APN to the
secondary algorithms (Figures 3a-3g) when the woman is using certain methods of
contraception, or once a positive or negative test result is determined.

The decision making points within both the primary and the secondary algorithms
are supported by the literature, and are cited as each algorithm is explained to the reader.
While the algorithm offers information to direct the APN to ask specific questions, it can
not include all of the information the APN should know related to client assessment, client
education and interventions appropriate to each client's needs. The APN who provides
pregnancy testing services needs to keep current with research and literature in women's
health care.

This algorithm reflects information and process components which are based on
current literature and empirical evidence. A primary resource for practical information
about family planning and contraception upon which this algorithm was developed is

1

2
Contraceptixelechnology by Hatcher, Tnissell, Stewart, Stewart, Kowal, Guest, Cates,
and Policar (1994). APNs who interact with women at the time of pregnancy testing need
to be familiar with this reference.
Use of The DeMann Algorithm could decrease health care costs, and enhance
health outcomes for women and their families. Agencies who adopt The DeMann
Algorithm could be in a more positive position to promote comprehensive services at a

crucial time in a woman's life.

3
Woman Requests a Pregnancy Test
6

Assess: Does she believe she's at
risk for pregnancy?

 

 

 

i
-——+

 

W

 

 

 

Oral contraception refer to Figure 3c
Depo-Provera refer to Figure 3d
Norplant refer to Figure 3e

IUD refer to Figure 3f

Tubal ligation refer to Figure 3g

+

 

 

Woman is not using one of the above methods of contraception

 

 

 

 

Date: .is she late?
Timing as expected?
Length as expected?

Amount of flow as expected?
Was menses "normal' '?

 

 

 

 

 

 

 

 

 

 

 

 

Minis is I“: 'or Menses is on time and
a no "normal"

i
Perform Pregnancy '19 W v

 

it tr
Is she concerned about a recent
sexual rexperittnce?
* +

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T
W '3' -
The woman with a The woman “’“h a "es m
positive pregnancy “333““ pregnancy F i
[CST test
DOCS She deSiN Ink—rm
‘ Pmncy? shamanism
i vb heLneerls
.es
Was sexualx expenence of
concern within the last
E I l seven *days?

 

Test accuracy and date to

return to clinic for FM -
!

accurate testing. Discuss

 

abstinence from tobacco.

 

alcohol and other drugs. MW
Discuss contraception if Initiate contraception servrces as
she is not seeking appropriate ‘0 woman's “(1065i

 

 

pregnancy.

 

 

 

Figure 3. The DeMann Algorithm: The Primary Assessment of the Woman Seeking

Pregnancy Testing.

h Woman wi 'v c t

 

WM

Missed 2 3 cycles?

Missed 2 6 months?

Postpartum/nonlactating and missed 2 12 weeks?
Postinduced abortion and missed 2 8 weeks?

 

 

 

 

 

 

 

 

 

 

 

 

 

V V
No to ALL of the above questions? Yes to ANY of the above questions.
( Does she desire pregnancy? ) Discuss Amengrrhgg;

 

 

 

$ - Initiate evaluation/services for
amenorrhea as appropriate to the

woman's needs.

Qisggss Contraception;

Initiate contraception as Has she been u-yjng to
appropriate to woman's conceive for > 1 year?
request.

Yes \

 

 

 

 

 

 

 

 

 

 

 

 

Discuss PI‘CCO i n e ic Disc 55 Infertilit ervic
Initiate preconception services as Initiate fertility services as
appropriate ‘0 her needs. appropriate to her needs.

 

 

5.2M: The DeMann Algorithm: The Woman with a Negative Pregnancy Test

 

5

The Woman with a Positive Pregnancy Test

 

Woman's reaction to positive test result.
Seeking pregnancy?

Raise the child?

Relinquish the child?

Terminate the pregnancy?

Undecided?

J
(:Itinuation of pregnaia @ Termination of pregnanE
l

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Woman wishes Woman wishes D' 5 . .
to "in Child to "mun-”h child WIDE W
; I Educate re: Educate re:
Ecourage prompt Need for prompt
D. 5 . . te , _ . decision to allow best intervention. Answer the
Wm WM intervention. discuss questions 0‘ woman
W agency of referral. regarding procedure.
I II n l
i v
E v' I 'II E E
I I I (I . I .
B I [I .I. | l I .
Education;
Review:

Gestational age
Importance of early prenatal care
Discuss OTC medication use in pregnancy.
Discuss exercise. nutrition in pregnancy.
Advise avoidance of alcohol. tobacco. and other drugs.
Advise woman to take information regarding family health history to first

prenatal visit.

til "w ill .. I II III III

I. Sudden intense pain or cramping in the lower abdomen which is usually

localized to one side.
2. Irregular vaginal bleeding or spotting with abdominal pain.
3. Fainting or dizziness which lasts more than a few seconds with or without

vaginal bleeding.

1. Heavy bleeding
2. Heavy uterine cramping
3. Passage of blood clots or clumps of tissue.

WNW

 

 

 

EM The DeMann Algorithm: The Woman with a Positive Pregnancy Test.

 

 

ll unconcerned re: tuned/late
ecenrreaual mater

t i

i t
W Aha-.1
Idle; m
WNUNC (mm Effectiveness (1 CC; I”

curs-rcpt": as needed when to return to CIIIIIC it
trusted menses cram

i
.E @
"'me .

 

  
  
   
   

 

 

“I“: [3; Side eltech of
00 Assess maroon
I'llh author! It the
united nth tier rnettrod1

i i

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

re . treat terns-mu.
latigtte. unnxy tre-
quency. WWW].
nipple tenant-try ‘.’

 

 

 

Mn; m Check
Accuracy of test. when ‘ BBT.c1tecuvt-rteu
to return to c1rnrc.brk- . - of 0C:. back-up

uprnethodsmmnauu _ nrmmJaumto

 

 

 

otlrce it 2 truest-d
mom a BET .s
9%! Satisfied with

checking BBT Assess
urru‘runn I‘llh rnethrt‘i
Is she “Infra! with

 

 

Accuracy of test. and when
to return to CIIDK tar
mung Dumas/initiate
”cementum sen'rccx

 

 

 

 

 

 

 

 

Mile. The DeMann Algorithm. The Woman Using Oral Contraceptives.

 

 
  
    

Date: Is she late? Timing as expected?
Length as expected? Amount of flow as expected?
Was menses "normal?”

./ *

 

 

 

 

 

 

 

 

 

 

 

[Yamis'hormafi [No-mammal]

i
W [isuteorisstinjtcums I4IeeISago‘31
W l

 

Wm.
Breast Tenderness was sexual encwmer of concern > [4 weeks
Faugue after Int injection?

N auseaNomitin g
Unitary Frequency

t i
t i

.......
Etiecuveneu of T“

DMPA. otter test I I

with lst occurrence
I Negativel Puitive

ii
i i

 

 

No-not at risk

i

   

     
   
   

Educate re: DMPA
side effect. Does she
desire WM?

i

with DMPA?
i i

 

 

 

 

 

 

 

 

   

 

 

 

mm
Side effects of
DMPA Assess
satisfied \Iv’llh $
method"
admit; mmmmm
' eded . .
$ + Pregnancy Test Test acniracy. as m $33M“
E $ ‘ when to return to

 

 

 

 

 

 

 

 

return Ior lesung.
W Discuss pomble l8
Contracepuve W months to conceive.

senices as "‘de ngfigcurc

 

clinic for testing
Positive mm
[2m accuracy of
tests and When to +

 

 

 

 

 

 

 

 

 

 

 

Cmuacepuw: WW
stmces W

 

 

 

 

 

Elm The DeMann Algorithm: The Woman Using Depo-Provera.

    
  
  

Date: [5 she late?
Timing as expected?

Length as expected?

Amount of flow as expected?
Was menses "normal?"

./ *

 

 

 

 

 

 

 

 

[ Yes menses was "normal." I No menses was not "normal." I
Wm
| I ,, v < Has she had a menses since lnsertioB
Educate/intervene as needed.

 

 

 

 

i +
Yes

Was Norplant inserted <6

weeks before the visit? Was

she at risk for pregnancy at

the time of insertion? J,

 

 

 

 

W
Yes —’ Breast Tenderness
$ Fatigue
Nausea/Vomiting
Perform Pregnancy Test ) Urinary Frequency

 

 

* * t t
+

Cs this her lst episode

 

of amenorrhea?

 

t t

 

{r

Perform Pregnancy Test )

+ iv
Side effects of Norplant
Effecriveness *
S f d thmethod?

i
i

 

 

 

 
  
   

 

 

 

 

 

 

W Want '
Hi I' .. C | I 5 v
appropriate to woman's needs

 

 

 

 

Elem. The DeMann Algorithm: The Woman Using Norplant.

9
II w '11' [III

Date: Is she late?
Timing as expected?

Length as expected?

Amount of flow as expected?
Was menses "normal?"

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes menses is 'normal." No menses is not "normal."
! s e 5 WI I ! li ves ! Perform Pregnancy TE
needs a test? +
W
Missed 2 3 cycles? [Ed—m5: . k f
Missed > 6 months? “Twas? r15 3
Postpartum/nonlactating missed > 12 weeks? eciic?a:e 12:ch
Postinduced abortion missed > 8 weeks? p l p g y.
Not to ALL 0f the Yes to ANY of the above
above questions. questions.

 

 

 

 

 

 

+ v

5.119% Amenorrhea ervices
Effectiveness of IUD
Assess client age, could she
be perimenopausal? Is she
having hot flushes or night
sweats?

i i

+ +

 

 

 

 

 

 

 

 

 

 

 

rim a W
Wm: 91 amenorrhea and whgn
en al c a e v r W
W
n at

 

 

 

Elm The DeMann Algorithm: The Woman Using an IUD

10

W

 

Alum
Date. _ hatielate‘.‘ fining-seam?
Lengthaseapeeted’.’ Amniofnowas

captained? Wumes'namal?‘

 

 

 

 

 

 

Misaedzilcycles?
Mmedzormnths‘.‘
Wmmuzma
Posunrhicedahuuonmineszweeks?

 

t

 

 

Ya “ANY of

the above
questions

 

 

t

Jr

 

W
“Ale-ni-
“Semen

 

 

 

Mor- Pregnancy
Test

t

J

«E

i

 

 

Net-ALL
oftheabeve

 

 

Perform Pregnutcy

“E

 

WI!
Educate re:
Increased risk of

«topic imxmncy

 

 

 

W

LE]

-\

l

 

[Meme-inn "mwl

 

t
t

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W
Educate; ~ Missed 2 3 cycles?
Increased risk of Missed z 6 tmnths"
WC WW“!- Posipenumiaumm; missed 2 i2 weeks?
Postuiduced abortion missed 2 8 wan?
No to ALL its team or
of the above the above
gum question
W
l m
m
Educate;

Transrent causes of amenorrhea. effectiveness
of tubal ligation. Asses: client age. mold the

be perimenopausal "

 

4

¢

 

 

Willi
W

‘and

[M

 

 

HEM The DeMann Algorithm: The Woman with a Tubal Ligation.

 

 

1]

References

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Chikotas, N (1995). Continuing education forum: Secondary amenorrhea. lQumal
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Christmas, J., Pirani, M ,,Heagarty A., & Schwartz, L. (1993) Prenatal Care.
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