Anatomy and physiology of pregnancy

Anatomy and physiology of pregnancy. Mathernal and fetal nutrition. Nursing care during pregnancy. Childbirth and Perinatal education

Prepared by assistant professor N.Petrenko, MD, PhD

 

LEARNING OBJECTIVES

* Determine gravidity and parity using the fiveand four-digit systems.

* Describe the various types of pregnancy tests.

* Explain the expected maternal anatomic and physiologic adaptations to pregnancy.

* Differentiate among presumptive, probable, and positive signs of pregnancy.

* Identify the maternal hormones produced during pregnancy, their target organs, and their major effects on pregnancy.

* Compare the characteristics of the abdomen, vulva, and cervix of the nullipara and multipara.

* DBScribe the process of confirming pregnancy and estimating the date of birth.

* Summarize the physical, psychosocial, and behavioral changes that usually occur as the mother and other family members adapt to pregnancy.

* Outline the patterns of health care provided to assess maternal and fetal health status at the initial and follow-up visits during pregnancy.

* Identify nursing assessments, diagnoses, interventions, and methods of evaluation that are typical when providing care for the pregnant woman.

* Discuss education needed by pregnant women to understand physical discomforts related to pregnancy and to recognize signs and symptoms of potential complications.

* Examine the impact of culture, age, parity, and number of fetuses on the response of the family to the pregnancy and on the prenatal care provided.

* Discuss the purpose of childbirth education and strategies used to provide appropriate information.

* Compare the options expectant families have  in choice of care providers, birth plans, and birth settings.

* Summarize the care of a woman who is battered during pregnancy.

* Explain recommended maternal weight gain during pregnancy.

* Compare the recommended level of intake of energy sources, protein, and key vitamins and minerals during pregnancy and lactation.

* Give examples of the food sources that provide the nutrients required for optimal maternal nutrition during pregnancy and lactation.

* Examine the role of nutrition supplements during pregnancy.

* List five nutritional risk factors during pregnancy.

* Compare the dietary needs of adolescent and mature pregnant women.

* Give examples of cultural food patterns and possible dietary problems for two ethnic groups or for two alternative eating patterns.

 

KEY TERMS AND DEFINITIONS

ballottement Diagnostic technique using palpation:  a floating fetus, when tapped or pushed, moves away and then returns to touch the examiner's hand

Braxton Hicks sign Mild, intermittent, painless uterine contractions that occur during pregnancy; occur more frequently as pregnancy advances but do not represent true labor; however, they should be distinguished from preterm labor

carpal tunnel syndrome Pressure on the median nerve at the point at which it goes through the carpal tunnel of the wrist; causes soreness, tenderness, and weakness of the muscles of the thumb

Chadwick sign Violet color of vaginal mucous membrane that is visible from approximately the fourth week of pregnancy; caused by increased vascularity

chloasma Increased pigmentation over bridge of nose and cheeks of pregnant women and some women taking oral contraceptives; also known as "mask of pregnancy"

colostrum Fluid in the acini cells of the breasts present from early pregnancy into the early postpartal period; rich in antibodies, which provide protection to the breastfed newborn from many diseases; high in protein, which binds bilirubin; and laxative acting, which speeds the elimination of meconium and helps loosen mucus

diastasis recti abdominis Separation of the two rectus muscles along the median line of the abdominal wall; often seen in women with repeated childbirths or with a multiple gestation (e.g., triplets)

epulis Tumorlike benign lesion of the gingiva seen in pregnant women

funic souffle Soft, muffled, blowing sound produced by blood rushing through the umbilical vessels and synchronous with the fetal heart sounds

Goodell sign Softening of the cervix, a probable sign of pregnancy, occurring during the second month

Hegar sign Softening of the lower uterine segment that is classified as a probable sign of pregnancy, may be present during the second and third months of pregnancy, and is palpated during bimanual examination

human chorionic gonadotropin (hCG) Hormone that is produced by chorionic villi; the biologic marker in pregnancy tests

leukorrhea White or yellowish mucus discharge from the cervical canal or the vagina that may be normal physiologically or caused by pathologic states of the vagina and endocervix

lightening Sensation of decreased abdominal distention produced by uterine descent into the pelvic cavity as the fetal presenting part settles into the pelvis; usually occurs 2 weeks before the onset of labor in nulliparas

linea nigra Line of darker pigmentation seen in some women during the latter part of pregnancy that appears on the middle of the abdomen and extends from the symphysis pubis toward the umbilicus

Montgomery tubercles Small, nodular prominences (sebaceous glands) on the areolas around the nipples of the breasts that enlarge during pregnancy and lactation

operculum Plug of mucus that fills the cervical canal during pregnancy

palmar erythema Rash on the surface of the palms sometimes seen in pregnancy

ptyalism Excessive salivation

pyrosis Burning sensation in the epigastric and sternal region from stomach acid (heartburn)

quickening Maternal perception of fetal movement; usually occurs between weeks 16 and 20 of gestation

striae gravidarum "Stretch marks"; shining reddish lines caused by stretching of the skin, often found on the abdomen, thighs, and breasts during pregnancy; these streaks turn to a fine pinkish white or silver tone in time in fair-skinned women and brownish in darker-skinned women

uterine souffle Soft, blowing sound made by the blood in the arteries of the pregnant uterus and synchronous with the maternal pulse

 

The goal of maternity care is a healthy pregnancy with a physically safe and emotionally satisfying outcome for mother, infant, and family. Consistent health supervision and surveillance are of utmost importance in achieving this outcome. However, many maternal adaptations are unfamiliar to pregnant women and their families. Helping the pregnant woman recognize the relationship between her physical status and the plan for her care assists her in making decisions and encourages her to participate in her own care.

 

GRAVIDITY AND PARITY

An understanding of the following terms used to describe pregnancy and the pregnant woman is essential to the study of maternity care:

• Gravida—a woman who is pregnant

• Gravidity—pregnancy

• Multigravida—a woman who has had two or more pregnancies

• Multipara—a woman who has completed two or more pregnancies to the stage of fetal viability

• Nulligravida—a woman who has never been pregnant

• Nullipara—a woman who has not completed a pregnancy with a fetus or fetuses who have reached the stage of fetal viability

• Parity—the number of pregnancies in which the fetus or fetuses have reached viability, not the number of fetuses (e.g., twins) born; whether the fetus is born alive or is stillborn (fetus who shows no signs of life at birth) after viability is reached does not affect parity

• Postdate or postterm—a pregnancy that goes beyond 42 weeks of gestation

• Preterm—a pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation

• Primigravida—a woman who is pregnant for the first time

• Primipara—a woman who has completed one pregnancy with a fetus or fetuses who have reached the stage of fetal viability

• Term—a pregnancy from the beginning of the thirtyeighth week of gestation to the end of the forty-second week of gestation

• Viability—capacity to live outside the uterus; approximately 22 to 24 weeks since last menstrual period, or weight of fetus is greater than 500 g

 

Gravidity and parity information is obtained during history-taking interviews and may be recorded in patient records in several ways. One abbreviation commonly used in maternity centers consists of five digits separated with hyphens. The first digit represents the total number of pregnancies, including the present one (gravidity); the second digit represents the total number of term births; the third indicates the number of preterm births; the fourth identifies the number of abortions (miscarriage or elective termination of pregnancy before viability); and the fifth is the number of children currently living. The acronym GTPAL (gravidity, term, preterm, abortions, living children) may be helpful in remembering this system of notation. For example, if a woman pregnant only once with twins gives birth at the thirty-fifth week and the babies survive, the abbreviation that represents this information is "1-0-1-0-2." During her next pregnancy the abbreviation is "2-0-1-0-2." Additional examples are given in Table 1.

Others prefer a four-digit system. The first digit of the five-digit system, which signifies gravidity, is dropped. The acronym TPAL may be useful in remembering what the four digits stand for.

 

Table 1 Gravidity and Parity Using  Five-Digit (GTPAL) System
	GRAVIDITY PREGNANCIES	TERM BIRTH	PRETERM BIRTH	ABORTIONS	LIVING CHILDREN
Sarah is pregnant for the first time.	1	0	0	0	0
She carries the pregnancy to term, and the neonate survives.	1	1	0	0	1
She is pregnant again.	2	1	0	0	1
Her second pregnancy ends in abortion.	2	1	0	1	1
During her third pregnancy, she gives birth to preterm twins.	3	1	1	1	3

 

PREGNANCY TESTS

Early detection of pregnancy allows for early initiation of care. Human chorionic gonadotropin (hCG) is the biologic marker on which pregnancy tests are based. Production of hCG begins as early as the day of implantation and can be detected in the blood as early as 6 days after conception, or approximately 20 days since the last menstrual period (LMP), and in urine approximately 26 days after conception (Cunningham et al., 2001). The level of hCG rises until it peaks at approximately 60 to 70 days of gestation and then begins to decline. The lowest level is reached between 100 and 130 days of pregnancy and remains constant until birth (Varney, 1997).

Serum and urine pregnancy tests are performed in clinics, offices, women's health centers, and laboratory settings. Both serum and urine tests provide accurate results. A 7- to 10-ml sample of venous blood is collected for serum testing. Most urine tests require a first-voided morning urine specimen because it contains levels of hCG approximately the same as those in serum. Random urine samples usually have lower levels. Urine tests are less expensive and provide more immediate results than serum tests (Hatcher et al., 1998).

Many different pregnancy tests are available, but they all depend on recognition of hCG or a beta subunit of hCG. The wide variety of tests precludes discussion of each; however, several categories of tests are described here. The nurse should read the manufacturer's directions for the test to be used.

Immunoassoys, or agglutination inhibition tests, depend on an antigen-antibody reaction between hCG and an antiserum. Usually, the antiserum is mixed with urine, and hCG-coated particles (e.g., latex or blood cells) are added. If hCG is present in the urine, agglutination does not occur because the hCG neutralizes the hCG antibody, and the test is considered positive (Cunningham et al., 2001). Although immunologic tests are accurate from 4 to 10 days after a missed period, they are most appropriate for confirming a pregnancy at or after the sixth week of gestation (Hatcher et al., 1998).

Radioimmunoassay pregnancy tests for the beta subunit of hCG in serum or urine samples use radioactively labeled markers and are usually performed in a laboratory. These tests are accurate with low hCG levels and can confirm pregnancy 1 week after conception (Hatcher et al., 1998).

Radioreceptor assay is a serum test that measures the ability of a blood sample to inhibit the binding of radiolabeled hCG to receptors. The test is 90% to 95% accurate from 6 to 10 days after conception (Pagana & Pagana, 2001).

Enzyme-linked immunosorbent assay (ELISA) testing is the most popular method of testing for pregnancy. It uses a specific monoclonal antibody (anti-hCG) with enzymes to bond with hCG in urine. Depending on the specific test, levels of hCG as low as 5 to 50 mlU/ml can be detected as early as 4 days after implantation (Hatcher et al., 1998). As an office or home procedure it requires minimal time and offers results in 5 minutes. A positive test is indicated by a simple color-change reaction.

ELISA technology is the basis for most over-thecounter home pregnancy tests. With these one-step tests, the woman usually applies urine to a strip and reads the results. The test kits come with directions for collection of the specimen, the testing procedure, and reading of the results. Most manufacturers of the kits provide a toll-free telephone number to call if users have concerns and questions about test procedures or results (see Teaching Guidelines box). The most common error in performing home pregnancy tests is doing the test too early in pregnancy (Hatcher et al., 1998).

 

TEACHING GUIDELINES Home Pregnancy Testing • Follow the manufacturer's instructions carefully. Do not omit steps. • Review the manufacturer's list of foods, medications, and other substances that can affect the test results. • Use a first-voided morning urine specimen. • If the test done at the time of your missed period is negative, repeat the test in 1 week if you still have not had a period. • If you have questions about the test, contact the manufacturer. • Contact your health care provider for follow-up if the test is positive or if the test is negative and you still have not had a period

 

Interpreting the results of pregnancy tests requires some judgment. The type of pregnancy test and its degree of sensitivity (ability to detect low levels of a substance) and specificity (ability to discern the absence of a substance) have to be considered in conjunction with the woman's history. This includes the date of her last normal menstrual period (LNMP), her usual cycle length, and results of previous pregnancy tests. It is important to know if the woman is a substance abuser and what medications she is taking, because medications such as anticonvulsants and tranquilizers can cause false-positive results and diuretics and promethazine can cause false-negative results (Pagana & Pagana, 2001). Improper collection of the specimen, hormone-producing tumors, and laboratory errors also may cause false results. Whenever there is any question, further evaluation or retesting may be appropriate.

ADAPTATIONS TO PREGNANCY

Maternal physiologic adaptations are attributed to the hormones of pregnancy and to mechanical pressures arising from the enlarging uterus and other tissues. These adaptations protect the woman's normal physiologic functioning, meet the metabolic demands pregnancy imposes on her body, and provide a nurturing environment for fetal development and growth. Although pregnancy is a normal phenomenon, problems can occur.

 

SIGNS OF PREGNANCY

Some of the physiologic adaptations are recognized as signs and symptoms of pregnancy. Three commonly used categories ofsigns and symptoms of pregnancy are presumptive, those changes felt by the woman (e.g., amenorrhea, fatigue, nausea and vomiting, breast changes);probable, those changes observed by an examiner (e.g., Hegar sign, ballottement, pregnancy tests); and positive, those signs that are attributed only to the presence of the fetus (e.g., hearing fetal heart tones, visualization of the fetus, and palpating fetal movements). Table 2 summarizes the signs of pregnancy in relation to when they might occur and other causes for their occurrence.

 

Table 2 Sign and Pregnancy
TIME OF OCCURRENCE (GESTATIONAL AGE)	SIGN	OTHER POSSIBLE CAUSE
PRESUMPTIVE SIGNS
3-4 wk	Breast changes	Premenstrual changes, oral contraceptives
4 wk	Amenorrhea	Stress, vigorous exercise, early menopause, endocrine problems, malnutrition
4-14 wk	Nausea, vomiting	Gastrointestinal virus, food poisoning
6-12 wk	Urinary frequency	Infection, pelvic tumors
12 wk	Fatigue	Stress, illness
16-20 wk	Quickening	Gas, peristalsis
PROBABLE SIGNS
5 wk	Goodell sign	Pelvic congestion
6-8 wk	Chadwick sign	Pelvic congestion
6-12 wk	Hegar sign	Pelvic congestion
4-12 wk	Positive pregnancy test (serum)	Hydatidiform mole, choriocarcinoma
6-12 wk	Positive result to pregnancy test (urine)	False-positive results may be caused by pelvic infection, tumors
16 wk	Braxton Hicks contractions	Myomas, other tumors
16-28 wk	Ballottement	Tumors, cervical polyps
POSITIVE SIGNS
5-6 wk	Visualization of fetus by real-time ultrasound examination	No other causes
16wk	Visualization of fetus by x-ray study
6 wk	Fetal heart tones detected by ultrasound examination
8-17 wk	Fetal heart tones detected by Doppler ultrasound stethoscope
17-19 wk	Fetal heart tones detected by fetal Stethoscope
19-22 wk	Fetal movements palpated
Late pregnancy	Fetal movements visible

 

REPRODUCTIVE SYSTEM AND BREASTS

Uterus

The phenomenal uterine growth in the first trimester is stimulated by high levels of estrogen and progesterone. Early uterine enlargement results from increased vascularity and dilation of blood vessels, hyperplasia (production of new muscle fibers and fibroelastic tissue) and hypertrophy (enlargement of preexisting muscle fibers and fibroelastic tissue), and development of the decidua. By 7 weeks of gestation, the uterus is the size of a large hen's egg; by 10 weeks of gestation, it is the size of an orange (twice its nonpregnant size); and by 12 weeks of gestation, it is the size of a grapefruit. After the third month, uterine enlargement is primarily the result of mechanical pressure of the growing fetus (Varney, 1997).

As the uterus enlarges, it also changes in shape and position. At conception the uterus is shaped like an upsidedown pear. During the second trimester, as the muscular walls strengthen and become more elastic, the uterus becomes spherical or globular. Later, as the fetus lengthens, the uterus becomes larger and more ovoid and rises out of the pelvis into the abdominal cavity.

The pregnancy may "show" after the fourteenth week, although this depends to some degree on the woman's height and weight. Abdominal enlargement may be less apparent in the nulipara with good abdominal muscle tone (Fig. 1). Posture also influences the type and degree of abdominal enlargement that occurs. In normal pregnancies the uterus enlarges at a predictable rate. As the uterus grows, it may be palpated above the symphysis pubis some time between the twelfth and fourteenth weeks of pregnancy (Fig. 2). The uterus rises gradually to the level of the umbilicus at 22 to 24 weeks of gestation and nearly reaches the xiphoid process at term. Between weeks 38 and 40, fundal height drops as the fetus begins to descend and engage in the pelvis (lightening) (Fig. 2, dashed line). Generally, lightening occurs in the nullipara approximately 2 weeks before the onset of labor and at the start of labor in the multipara.

 

Fig. 1 Comparison of abdomen, vulva, and cervix in nullipara

(A) and multipara (B) at the same stage of pregnancy.

 

 

Fig. 2 Height of fundus by weeks of normal gestation with a single fetus. Dashed line indicates height after lightening. (From Seidel, H. et al. [1999]. Mosby's guide to physical examination [4th ed.]. St. Louis: Mosby.)

 

Uterine enlargement is determined by measuring fundal height, a measurement commonly used to estimate the duration of pregnancy. However, variation in the position of the fundus or the fetus, variations in the amount of amniotic fluid present, the presence of more than one fetus, maternal obesity, and variation in examiner techniques can reduce the accuracy of this estimation of the duration of pregnancy.

The uterus normally rotates to the right as it elevates, probably because of the presence of the rectosigmoid colon on the left side. However, the extensive hypertrophy (enlargement) of the round ligaments keeps the uterus in the midline. Eventually, the growing uterus touches the anterior abdominal wall and displaces the intestines to either side of the abdomen (Fig. 3). When a pregnant woman is standing, most of her uterus rests against the anterior abdominal wall, and this contributes to altering her center of gravity.

 

 

Fig. 3 Displacement of internal abdominal structures and diaphragm by the enlarging uterus at 4, 6, and 9 months of gestation.

 

At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment (the uterine isthmus) occur (Hegar sign). This results in exaggerated uterine anteflexion during the first 3 months of pregnancy (Fig. 4). In this position the uterine fundus presses on the urinary bladder, causing the woman to experience urinary frequency.

 

Fig. 4 Hegar sign. Bimanual examination for assessing compressibility, softening of isthmus (lower uterine segment) while the cervix is still firm.

 

Early uterine enlargement may not be symmetric, depending on the site of implantation. For example, if corneal implantation occurred, a soft, irregular bulge (Piskacek sign) may be detected during a pelvic examination (Varney, 1997).

Changes in contractility. Soon after the fourth month of pregnancy, uterine contractions can be felt through the abdominal wall. These contractions are referred to as the Braxton Hicks sign. Braxton Hicks contractions are irregular, painless contractions that occur intermittently throughout pregnancy. These contractions facilitate uterine blood flow through the intervillous spaces of the placenta and thereby promote oxygen delivery to the fetus. Although Braxton Hicks contractions are not painful, some women do complain that they are annoying. After the twenty-eighth week, these contractions become much more definite, but they usually cease with walking or exercise. Braxton Hicks contractions can be mistaken for preterm and true labor; however, they do not increase in intensity or frequency or cause cervical dilation.

Uteroplacental blood flow. Placental perfusion depends on the maternal blood flow to the uterus. Blood flow increases rapidly as the uterus increases in size. Although uterine blood flow increases twentyfold, the fetoplacental unit grows more rapidly. Consequently, more oxygen is extracted from the uterine blood during the latter part of pregnancy (Cunningham et al., 2001). In a normal term pregnancy, one sixth of the total maternal blood volume is within the uterine vascular system. The rate of blood flow through the uterus averages 500 ml/min, and oxygen consumption of the gravid uterus increases to meet fetal needs. A low maternal arterial pressure, contractions of the uterus, and maternal supine position are three factors known to decrease blood flow. Estrogen stimulation may increase uterine blood flow. Doppler ultrasound can be used to measure uterine blood flow velocity, especially in pregnancies at risk because of conditions associated with decreased placental perfusion such as hypertension, intrauterine growth restriction, diabetes mellitus, and multiple gestation (Creasy & Resnik, 1999). Using an ultrasound device or a fetal stethoscope, the health care provider may hear the uterine soufflé or the funic souffle.

Cervical changes. A softening of the cervical tip called Goodell sign may be observed at approximately the beginning of the sixth week in a normal, unscarred cervix. This sign is brought about by increased vascularity, slight hypertrophy, and hyperplasia (increase in number of cells) of the muscle and its collagen-rich connective tissue, which becomes loose, edematous, highly elastic, and increased in volume. The glands near the external os proliferate beneath the stratified squamous epithelium, giving the cervix the velvety appearance characteristic of pregnancy. Friability is increased and may cause slight bleeding after coitus with deep penetration or after vaginal examination. Pregnancy can also cause the squamocolumnar junction, the site for obtaining cells for cervical cancer screening, to be located away from the cervix. Because of all these changes, evaluation of abnormal Papanicolaou tests during pregnancy can be complicated. However, careful assessment of all pregnant women is important because approximately 3% of all cervical cancers are diagnosed during pregnancy (Creasy & Resnik, 1999).

The cervix of the nullipara is rounded. Lacerations of the cervix almost always occur during the birth process. With or without lacerations, however, after childbirth the cervix becomes more oval in the horizontal plane, and the external os appears as a transverse slit (see Fig. 1).

Changes related to the presence of the fetus. Passive movement of the unengaged fetus is called ballottement and can be identified generally between the sixteenth and eighteenth week. Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and a gentle tap is felt on the finger (Fig. 5).

 

Fig. 5 Internal ballottement (18 weeks).

 

The first recognition of fetal movements, or "feeling life," by the multiparous woman may occur as early as the fourteenth to sixteenth week. The nulliparous woman may not notice these sensations until the eighteenth week or later. Quickening is commonly described as a flutter and is difficult to distinguish from peristalsis. Gradually, fetal movements increase in intensity and frequency. The week when quickening occurs provides a tentative clue in dating the duration of gestation.

 

Vagina and vulva

Pregnancy hormones prepare the vagina for stretching during labor and birth by causing the vaginal mucosa to thicken, connective tissue to loosen, smooth muscle to hypertrophy, and the vaginal vault to lengthen. Increased vascularity results in a violet-bluish color of the vaginal mucosa and cervix. The deepened color, termed Chadwick sign, may be evident as early as the sixth week, but is easily noted at the eighth week of pregnancy (Creasy & Resnik, 1999).

Leukorrhea is a white or slightly gray mucoid discharge with a faint musty odor. This copious mucoid fluid occurs in response to cervical stimulation by estrogen and progesterone. The fluid is whitish because of the presence of many exfoliated vaginal epithelial cells caused by hyperplasia of normal pregnancy. This vaginal discharge is never pruritic or blood stained. Because of the progesterone effect, ferning usually does not occur in the dried cervical mucous smear, as it would in a smear of amniotic fluid. Instead, a beaded or cellular crystallizing pattern formed in the dried mucus is seen (Cunningham et al., 2001). The mucus fills the endocervical canal, resulting in the formation of the mucous plug (operculum) (Fig. 6). The operculum acts as a barrier against bacterial invasion during pregnancy

 

Fig. 6 A, Cervix in nonpregnant woman. B, Cervix during pregnancy.

 

During pregnancy, the pH of vaginal secretions ranges from approximately 3.5 to 6. The increased production of lactic acid in the vaginal epithelium, probably caused by increased estrogen levels, produces a more acid environment. However, the pregnant woman is more vulnerable to some vaginal infections, especially yeast infections (Bennett & Brown, 1999).

The increased vascularity of the vagina and other pelvic viscera results in a marked increase in sensitivity. The increased sensitivity may lead to a high degree of sexual interest and arousal, especially during the second trimester of pregnancy. The increased congestion plus the relaxed walls of the blood vessels and the heavy uterus may result in edema and varicosities of the vulva. The edema and varicosities usually resolve during the postpartum period.

External structures of the perineum are enlarged during pregnancy because of an increase in vasculature, hypertrophy of the perineal body, and deposition of fat (Fig. 7). The labia majora of the nullipara approximate and obscure the vaginal introitus; those of the parous woman separate and gape after childbirth and perineal or vaginal injury. Fig. 1 compares the perineum of the nullipara and the multipara in relation to the pregnant abdomen, vulva, and cervix.

 

 

Fig. 7 A, Pelvic floor in nonpregnant woman. B, Pelvic floor at end of pregnancy. Note marked hypertrophy and hyperplasia below dashed line joining tip of coccyx and inferior margin of symphysis. Note elongation of bladder and urethra as a result of compression. Fat deposits are increased.

 

Breasts

Fullness, heightened sensitivity, tingling, and heaviness of the breasts begins in the early weeks of gestation in response to increased levels of estrogen and progesterone. Breast sensitivity varies from mild tingling to sharp pain. Nipples and areolae become more pigmented; secondary pinkish areolae develop, extending beyond the primary areolae; and nipples become more erectile. Hypertrophy of the sebaceous (oil) glands embedded in the primary areolae, called Montgomery tubercles , may be seen around the nipples. These sebaceous glands may have a protective role in that they keep the nipples lubricated for breastfeeding.

The richer blood supply causes the vessels beneath the skin to dilate. Once barely noticeable, the blood vessels become visible, often appearing in an intertwining blue network beneath the surface of the skin. Venous congestion in the breasts is more obvious in primigravidas. Striae gravidarum may appear at the outer aspects of the breasts.

During the second and third trimesters, growth of the mammary glands accounts for the progressive breast enlargement. The high levels of luteal and placental hormones in pregnancy promote proliferation of the lactiferous ducts and lobule-alveolar tissue, so palpation of the breasts reveals a generalized, coarse nodularity. Glandular tissue displaces connective tissue, and as a result the tissue becomes softer and looser.

Although development of the mammary glands is functionally complete by midpregnancy, lactation is inhibited until a drop in estrogen level occurs after the birth. A thin, clear, viscous secretory material (precolostrum) can be found in the acini cells by the third month of gestation.

Colostrum, the creamy, white/yellowish to orange premilk fluid, may be expressed from the nipples as early as 16 weeks of gestation (Lawrence, 1999). See Chapter 20 for discussion of lactation.

 

GENERAL BODY SYSTEMS

Cardiovascular system

Maternal adjustments to pregnancy involve extensive changes in the cardiovascular system, both anatomic and physiologic. Cardiovascular adaptations protect the woman's normal physiologic functioning, meet the metabolic demands pregnancy imposes on her body, and provide for fetal developmental and growth needs.

Slight cardiac hypertrophy (enlargement) is probably secondary to the increased blood volume and cardiac output that occurs. The heart returns to its normal size after childbirth. As the diaphragm is displaced upward by the enlarging uterus, the heart is elevated upward and rotated forward to the left (Fig. 8). The apical impulse, a point of maximum intensity, is shifted upward and laterally approximately 1 to 1.5 cm. The degree of shift depends on the duration of pregnancy and the size and position of the uterus.

 

 

Fig. 8 Changes in position of heart, lungs, and thoracic cage in pregnancy. Dashed line, nonpregnant; solid line, change that occurs in pregnancy.

 

The changes in heart size and position and increases in blood volume and cardiac output contribute to auscultatory changes common in pregnancy. There is more audible splitting of Sx and S2, and S, may be readily heard after 20 weeks of gestation. In addition, systolic and diastolic murmurs may be heard over the pulmonic area. These are transient and disappear shortly after the woman gives birth (Cunningham et al., 2001).

Between 14 and 20 weeks of gestation, the pulse increases approximately 10 to 15 beats per minute (beats/ min), which then persists to term. Palpitations may occur. In twin gestations, the maternal heart rate increases significantly in the third trimester (Creasy & Resnik, 1999).

The cardiac rhythm may be disturbed. The pregnant woman may experience sinus arrhythmia, premature atrial contractions, and premature ventricular systole. In the healthy woman with no underlying heart disease, no therapy is needed; however, women with preexisting heart disease will need close medical and obstetric supervision during pregnancy.

Blood pressure. Arterial blood pressure (brachial artery) is affected by age, activity level, and presence of health problems. Additional factors must be considered during pregnancy. These factors include maternal anxiety, maternal position, and size and type of blood pressure apparatus.

Maternal anxiety can elevate readings. If an elevated reading is found, the woman is given time to rest, and the reading is repeated.

Maternal position affects readings. Brachial blood pressure is highest when the woman is sitting, lowest when she is lying in the lateral recumbent position, and intermediate when she is supine, except for some women who experience supine hypotensive syndrome (see following discussion). Therefore, at each prenatal visit, the reading should be obtained in the same arm and with the woman in the same position. The position and arm used should be recorded along with the reading.

The proper size cuff is absolutely necessary for accurate readings. The cuff should be 20% wider than the diameter of the arm around which it is wrapped, or approximately 12 to 14 cm for average-sized individuals and 18 to 20 cm for obese persons. Too small a cuff yields a false-high reading; too large a cuff yields a false-low reading. Caution should also be used when comparing auscultatory and oscillatory blood pressure readings because discrepancies can occur (Green & Froman, 1996).

In the first trimester, blood pressure usually remains the same as the prepregnancy level. During the second trimester, there is a decrease in both systolic and diastolic pressure of 5 to 10 mm Hg. This decrease is probably the result of peripheral vasodilation caused by hormonal changes that occur during pregnancy. During the third trimester, maternal blood pressure should return to the first-trimester levels.

Calculating the mean arterial pressure (MAP) (mean of the blood pressure in the arterial circulation) can increase the diagnostic value of the findings. Normal MAP readings in the nonpregnant woman are 86.4 ± 7.5 mm Hg. MAP readings for a pregnant woman are slightly higher (Creasy 6 Resnik, 1999). One way to calculate MAP is illustrated in Box 1

Box 1 Calculation of Mean Arterial Pressure (MAP)

 

Some degree of compression of the vena cava occurs in all women who lie flat on their backs during the second half of pregnancy . Some women experience a fall in their systolic blood pressure of more than 30 mm Hg. After 4 to 5 minutes a reflex bradycardia is noted, cardiac output is reduced by half, and the woman feels faint. This condition is termed supine hypotensive syndrome (Cunningham et al., 2001).

Compression of the iliac veins and inferior vena cava by the uterus causes increased venous pressure and reduced blood flow in the legs (except when the woman is in the lateral position). These alterations contribute to the dependent edema, varicose veins in the legs and vulva, and hemorrhoids that develop in the latter part of term pregnancy (Fig. 9).

 

 

Fig. 9 Hemorrhoids. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

 

Blood volume and composition. The degree of blood volume expansion varies considerably. Blood volume increases by approximately 1500 ml, or 40% to 45% above nonpregnancy levels (Cunningham et al., 2001). This increase consists of 1000 ml of plasma plus 450 ml of red blood cells (RBCs). The blood volume starts to increase at approximately the tenth to twelfth week, peaks at approximately the thirty-second to thirty-fourth week, then decreases slightly at the fortieth week. The increase in volume of a multiple gestation is greater than that for a pregnancy with a single fetus (Creasy & Resnik, 1999). Increased volume is a protective mechanism. It is essential for meeting the blood volume needs of the hypertrophied vascular system of the enlarged uterus, adequately hydrating fetal and maternal tissues when the woman assumes an erect or a supine position, and providing a fluid reserve to compensate for blood loss during birth and the puerperium. Peripheral vasodilation maintains a normal blood pressure despite the increased blood volume in pregnancy.

During pregnancy there is an accelerated production of RBCs (normal 4.2 to 5.4 million/mm3). The percentage of increase depends on the amount of iron available. The RBC mass increases by approximately 17% (Creasy & Resnik, 1999).

Because the plasma increase exceeds the increase in RBC production, there is a decrease in normal hemoglobin values (12 to 16 g/dl blood) and hematocrit values (37% to 47%). This state of hemodilution is referred to as physiologic anemia. The decrease is more noticeable during the second trimester, when rapid expansion of blood volume takes place faster than RBC production. If the hemoglobin value drops to 10 g/dl or less or if the hematocrit drops to 35% or less, the woman is considered anemic.

The total white cell count increases during the second trimester and peaks during the third trimester. This increase is primarily in the granulocytes; the lymphocyte count stays approximately the same throughout pregnancy. See Table 3 for laboratory values during pregnancy.

 

Table 3 Laboratory values for Pregnant and Nonpregnant Women
HEMATOLOGIC VALUES Complete Blood Count (CBC)
Hemoglobin (g/dl)	12-16*	>11*
Hematocrit, packed cell volume (%)	37-47	>33*
Red blood cell (RBC) volume (per ml)	1600	1500-1900
Plasma volume (per ml)	2400	3700
RBC count (million/mm3)	4.2-5.4	5-6.25
White blood cells (total per mm3)	5000-10,000	5000-15,000
Neutophils (%)	55-70	60-85
Lymphocytes (%)	20-40	15-40
Erythrocyte sedimentation rate (mm/hr)	20	Elevated second and third trimesters
Mean corpuscular hemoglobin concentration (MCHC) (g/dl packed RBCs)	32-36	No change hemoglobin concentration
Mean corpuscular hemoglobin (MCH) (pg)	27-31	No change per picogram (less than a nanogram)
Mean corpuscular volume (MCV) (yu.m3)	80-95	No change per cubic micrometer
Blood Coagulation and Fibrinolytic Activityt
Factor	65-140	Increase in pregnancy, return to normal in early puerperium; factor VIII increases during and immediately after birth
Factor	55-145
Factor	60-140
Factor	45-155
Factor	65-135	Decrease in pregnancy
Factor	50-150
Prothrombin time (PT) (sec)	11-12.5	Slight decrease in pregnancy
Partial thromboplastin time (PTT) (sec)	60-70	Slight decrease in pregnancy, and decreases further during second and third stages of labor (indicates clotting at placental site)
Bleeding time (min)	1-9 (Ivy)	No appreciable change
Coagulation time (min)	6-10 (Lee/White)	No appreciable change
Platelets (per mm3)	150,000-400,000	No significant change until 3-5 days after birth and then a rapid increase (may predispose woman to thrombosis) and gradual return to normal
Fibrinolytic activity		Decreases in pregnancy and then abrupt return to normal (protection against thromboembolism)
Fibrinogen (mg/dl)	200-400	Increased levels late in pregnancy
Mineral/Vitamin Concentrations
Vitamin B12, folic acid, ascorbic acid
Serum proteins Total (g/dl) Albumin (g/dl) Globulin, total (g/dl)	6.4-8.3 3.5-5.0 2.3-3.4	5.5-7.5 Slight increase 3-4
Blood glucose Fasting (mg/dl) 2-Hour postprandial (mg/dl)	70-105 <140	Decreases <140 after a 100-g carbohydrate meal is considerednormal
Acid-Base Values in Arterial Blood
Po2	80-100	104-108 (increased)
Pco2	35-45	27-32 (decreased)
Sodium bicarbonate (HCO3) (mEq/L)	21-28	18-31 (decreased)
Blood	7.35-7.45	7.40-7.45 (slightly increased —more alkaline)
HEPATIC VALUES
Bilirubin total (mg/dl)	Not more than 1 mg/dl	Unchanged
Serum cholesterol (mg/dl)	120-200	Increases from 16-32 weeks of pregnancy; remains at this level until after birth
Serum alkaline phosphatase (U/L)	30-120	Increases from week 12 of pregnancy to 6 weeks after birth
Serum albumin (g/dl)	3.5-5	Slight increase
RENAL VALUES
Bladder capacity (ml)	1300	1500
Renal plasma flow (RPF) (ml/min	490-700	Increase by 25%-30%
Glomerular filtration rate (GFR) (ml/min)	88-128	Increase by 30%-50%
Nonprotein nitrogen (NPN) (mg/dl)	25-40	Decreases
Blood urea nitrogen (BUN) (mg/dl)	10-20	Decreases
Serum creatinine (mg/dl)	0.5-1.1	Decreases
Serum uric acid (mg/dl)	2.7-7.3	Decreases
Urine glucose	Negative	Present in 20% of pregnant women
Intravenous pyelogram (IVP)	Normal	Slight to moderate hydroureter and hydronephrosis; right kidney larger than left kidney

 

Cardiac output. Cardiac output increases from 30% to 50% over the nonpregnant rate by the thirty-second week of pregnancy; it declines to approximately a 20% increase at 40 weeks of gestation. This elevated cardiac output is largely a result of increased stroke volume and heart rateand occurs in response to increased tissue demands for oxygen (Creasy & Resnik, 1999). Cardiac output in late pregnancy is appreciably higher when the woman is in the lateral recumbent position than when she is supine. In the supine position, the large, heavy uterus often impedes venous return to the heart and affects blood pressure. Cardiac output increases with any exertion, such as labor and birth. (Table 4 summarizes cardiovascular changes in pregnancy.)

 

TABLE 4 Cardiovascular Changes in Pregnancy
Heart rate	Increases 10-15 beats/min
Blood pressure	Remains at prepregnancy levels in first trimester Slight decrease in second trimester Returns to prepregnancy levels in third trimester
Blood volume	Increases by 1500 ml or 40%-45% above prepregnancy level
Red blood cell mass	Increases 17%
Hemoglobin	Decreases
Hematocrit	Decreases
White blood cell count	Increases in second and third trimester
Cardiac output	Increases 30%-50%

 

Circulation and coagulation times. The circulation time decreases slightly by week 32. It returns to near normal near term. There is a greater tendency for blood to coagulate (clot) during pregnancy because of increases in various clotting factors (factors VII, VIII, IX, X, and fibrinogen). This, combined with the fact that fibrinolytic activity (the splitting up or the dissolving of a clot) is depressed during pregnancy and the postpartum period, provides a protective function to decrease the chance of bleeding but also makes the woman more vulnerable to thrombosis, especially after cesarean birth.

 

Respiratory system

Structural and ventilatory adaptations occur during pregnancy to provide for maternal and fetal needs. Maternal oxygen requirements increase in response to the acceleration in the metabolic rate and the need to add to the tissue mass in the uterus and breasts. In addition, the fetus requires oxygen and a way to eliminate carbon dioxide.

Elevated levels of estrogen cause the ligaments of the rib cage to relax, permitting increased chest expansion (see Fig. 8). The transverse diameter of the thoracic cage increases by approximately 2 cm, and the circumference increases by 6 cm (Cunningham et al., 2001). The costal angle increases and the lower rib cage appears to flare out. The chest may not return to its prepregnant state after birth (Seidel et al., 1999).

The diaphragm is displaced by as much as 4 cm during pregnancy. As pregnancy advances, thoracic (costal) breathing replaces abdominal breathing, and it becomes less possible for the diaphragm to descend with inspiration. Thoracic breathing is primarily accomplished by the diaphragm rather than by the costal muscles (Creasy & Resnik, 1999).

The upper respiratory tract becomes more vascular in response to elevated levels of estrogen. As the capillaries become engorged, edema and hyperemia develop within the nose, pharynx, larynx, trachea, and bronchi. This congestion within the tissues of the respiratory tract gives rise to several conditions commonly seen during pregnancy. These conditions include nasal and sinus stuffiness, epistaxis (nosebleed), changes in the voice, and a marked inflammatory response that can develop into a mild upper respiratory infection.

Increased vascularity of the upper respiratory tract also can cause the tympanic membranes and eustachian tubes to swell, giving rise to symptoms of impaired hearing, earaches, or a sense of fullness in the ears.

Pulmonary function. Respiratory changes in pregnancy are related to the elevation of the diaphragm and chest wall changes (Creasy & Resnik, 1999). Changes in the respiratory center result in a lowered threshold for carbon dioxide. The actions of progesterone and estrogen are presumed responsible for the increased sensitivity of the respiratory center to carbon dioxide. In addition, pregnant women become more aware of the need to breathe; some may even complain of dyspnea at rest. (See Table 5 for respiratory changes in pregnancy.)

 

Table 5 Respiratory Changes in Pregnancy
Respiratory rate	Unchanged or slightly increased
Tidal volume	Increased 30%-40%
Vital capacity	Unchanged
Inspiratory	Increased
Expiratory	Decreased
Total	Unchanged to slightly decreased
Oxygen consumption	Increased 15%-20%

 

Although pulmonary function is not impaired by pregnancy, diseases of the respiratory tract may be more serious during this time (Cunningham et al., 2001). One important factor responsible for this may be the increased oxygen requirement.

Basal metabolism rate. The basal metabolism rate (BMR) varies considerably in women at the beginning of and during pregnancy, although it usually increases by 15% to 20% at term (Worthington-Roberts & Williams, 1997). The BMR returns to nonpregnant levels by 5 to 6 days postpartum. The elevation in BMR during pregnancy reflects increased oxygen demands of the uterineplacental-fetal unit and greater oxygen consumption because of increased maternal cardiac work (Chamberlain & Pipkin, 1998). Peripheral vasodilation and acceleration of sweat gland activity help dissipate the excess heat resulting from the increased BMR during pregnancy. Pregnant women may experience heat intolerance, which is annoying to some women. Lassitude and fatigability after only slight exertion are experienced by many women in early pregnancy. These feelings, along with a greater need for sleep, may persist and may be caused in part by the increased metabolic activity.

Acid-base balance. Around the tenth week of pregnancy, there is a decrease of approximately 5 mm Hg in the partial pressure of carbon dioxide (PCO2). Progesterone may be responsible for increasing the sensitivity of the respiratory center receptors so that tidal volume is increased and PCO2 falls, the base excess (HCO3, or bicarbonate) falls, and pH increases slightly. These alterations in acidbase balance indicate that pregnancy is a state of respiratory alkalosis compensated by mild metabolic acidosis (Chamberlain & Pipkin, 1998). These changes also facilitate the transport of CO2 from the fetus and O2 release from the mother to the fetus (see Table 3).

 

Renal system

The kidneys are responsible for maintaining electrolyte and acid-base balance, regulating extracellular fluid volume, excreting waste products, and conserving essential nutrients.

Anatomic changes. Changes in renal structure during pregnancy result from hormonal activity (estrogen and progesterone), pressure from an enlarging uterus, and an increase in blood volume. As early as the tenth week of pregnancy, the renal pelves and the ureters dilate. Dilation of the ureters is more pronounced above the pelvic brim, in part because they are compressed between the uterus and the pelvic brim. In most women the ureters below the pelvic brim are of normal size. The smooth muscle walls of the ureters undergo hyperplasia and hypertrophy and muscle tone relaxation. The ureters elongate, become tortuous, and form single or double curves. In the latter part of pregnancy, the renal pelvis and ureter are dilated more on the right side than on the left because the heavy uterus is displaced to the right by the sigmoid colon.

Because of these changes, a larger volume of urine is held in the pelves and ureters, and urine flow rate is slowed. The resulting urinary stasis or stagnation has the following consequences:

• There is a lag between the time urine is formed and when it reaches the bladder. Therefore clearance test results may reflect substances contained in glomerular filtrate several hours before.

• Stagnated urine is an excellent medium for the growth of microorganisms. In addition, the urine of pregnant women contains more nutrients, including glucose, thereby increasing the pH (making the urine more alkaline). This makes pregnant women more susceptible to urinary tract infection.

Bladder irritability, nocturia, and urinary frequency and urgency (without dysuria) are commonly reported in early pregnancy. Near term, bladder symptoms may return, especially after lightening occurs.

Urinary frequency results initially from increased bladder sensitivity and later from compression of the bladder (see Fig. 7). In the second trimester the bladder is pulled up out of the true pelvis into the abdomen. The urethra lengthens to 7.5 cm as the bladder is displaced upward. The pelvic congestion that occurs in pregnancy is reflected in hyperemia of the bladder and urethra. This increased vascularity causes the bladder mucosa to be traumatized and bleed easily. Bladder tone may decrease, which increases the bladder capacity to 1500 ml. At the same time the bladder is compressed by the enlarging uterus, resulting in the urge to void even if the bladder contains only a small amount of urine.

Functional changes. In normal pregnancy, renal function is altered considerably. Glomerular filtration rate (GFR) and renal plasma flow increase early in pregnancy (Cunningham et al., 2001). These changes are caused by pregnancy hormones, an increase in blood volume, the woman's posture, physical activity, and nutritional intake. The woman's kidneys must manage the increased metabolic and circulatory demands of the maternal body and also excretion of fetal waste products. Renal function is most efficient when the woman lies in the lateral recumbent position and least efficient when the woman assumes a supine position. A side-lying position increases renal perfusion, which increases urinary output and decreases edema. When the pregnant woman is lying supine, the heavy uterus compresses the vena cava and the aorta, and cardiac output decreases. As a result, blood flow to the brain and heart is continued at the expense of other organs, including the kidneys and uterus.

Fluid and electrolyte balance. Selective renal tubular reabsorption maintains sodium and water balance regardless of changes in dietary intake and losses through sweat, vomitus, or diarrhea. From 500 to 900 mEq of sodium is normally retained during pregnancy to meet fetal needs. To prevent excessive sodium depletion, the maternal kidneys undergo a significant adaptation by increasing tubular reabsorption. Because of the need for increased maternal intravascular and extracellular fluid volume, additional sodium is needed to expand fluid volume and to maintain an isotonic state. As efficient as the renal system is, it can be overstressed by excessive dietary sodium intake or restriction or by use of diuretics. Severe hypovolemia and reduced placental perfusion are two consequences of using diuretics during pregnancy.

The capacity of the kidneys to excrete water during the early weeks of pregnancy is more efficient than later in pregnancy. As a result, some women feel thirsty in early pregnancy because of the greater amount of water loss. The pooling of fluid in the legs in the latter part of pregnancy decreases renal blood flow and GFR. This pooling of blood in the lower legs is sometimes referred to as physiologic edema or dependent edema and requires no treatment. The normal diuretic response to the water load is triggered when the woman lies down, preferably on her side, and the pooled fluid reenters general circulation.

Normally, the kidney reabsorbs almost all of the glucose and other nutrients from the plasma filtrate. In pregnant women, however, tubular reabsorption of glucose is impaired so that glucosuria occurs at varying times and to varying degrees. Normal values range from 0 to 20 mg/dl, meaning that during any one day the urine is sometimes positive and sometimes negative. In nonpregnant women, blood glucose levels must be at 160 to 180 mg/dl before glucose is "spilled" into the urine (not reabsorbed). During pregnancy, glycosuria occurs when maternal glucose levels are lower than 160 mg/dl. Why glucose, as well as other nutrients such as amino acids, is wasted during pregnancy is not understood, nor has the exact mechanism been discovered. Although glycosuria may be found in normal pregnancies (2 + levels may be seen with increased anxiety states), the possibility of diabetes mellitus and gestational diabetes must be kept in mind.

Proteinuria usually does not occur in normal pregnancy except during labor or after birth (Cunningham et al., 2001). However, the increased amount of amino acids that must be filtered may exceed the capacity of the renal tubules to absorb it, so small amounts of protein are then lost in the urine. Values of trace to +1 protein (dipstick assessment) or less than 300 mg/24 hr are acceptable during pregnancy (Creasy & Resnik, 1999). The amount of protein excreted is not an indication of the severity of renal disease, nor does an increase in protein excretion in a pregnant woman with known renal disease necessarily indicate a progression in her disease. However, a pregnant woman with hypertension and proteinuria must be carefully evaluated because she may be at greater risk for an adverse pregnancy outcome (see Table 3).

 

Integumentary system

Alterations in hormonal balance and mechanical stretching are responsible for several changes in the integumentary system during pregnancy. Hyperpigmentation is stimulated by the anterior pituitary hormone melanotropin, which is increased during pregnancy. Darkening of the nipples, areolae, axillae, and vulva occurs at approximately the sixteenth week of gestation. Facial melasma, also called chloasma or "mask of pregnancy," is a blotchy, brownish hyperpigmentation of the skin over the cheeks, nose, and forehead, especially in dark-complexioned pregnant women. Chloasma appears in 50% to 70% of pregnant women, beginning after the sixteenth week and increasing gradually until term. The sun intensifies this pigmentation in susceptible women. Chloasma caused by normal pregnancy usually fades after birth.

The linea nigra (Fig. 10) is a pigmented line extending from the symphysis pubis to the top of the fundus in the midline; this line is known as the linea alba before hormoneinduced pigmentation. In primigravidas the extension of the linea nigra, beginning in the third month, keeps pace with the rising height of the fundus; in multigravidas the entire line often appears earlier than the third month. Not all pregnant women develop linea nigra.

 

 

Fig. 10 Linea nigra. (From Seidel, H. et al. [1999]. Mosby's guide to physical examination [4th ed.]. St. Louis: Mosby.)

 

Striae gravidarum, or stretch marks (seen over lower abdomen in Fig. 11), which appear in 50% to 90% of pregnant women during the second half of pregnancy, may be caused by action of adrenocorticosteroids. Striae reflect separation within the underlying connective (collagen) tissue of the skin. These slightly depressed streaks tend to occur over areas of maximum stretch (i.e., abdomen, thighs, and breasts). The stretching sometimes causes a sensation that resembles itching. The tendency to develop striae may be familial. After birth they usually fade, although they never disappear completely. Color of striae varies depending on the pregnant woman's skin color. The striae appear pinkish on a woman with light skin and are lighter than surrounding skin in dark-skinned women. In the multipara, in addition to the striae of the present pregnancy, glistening silvery lines (in light-skinned women) or purplish lines (in dark-skinned women) are commonly seen. These represent the scars of striae from previous pregnancies.

 

Fig. 11 Striae gravidarum, or "stretch marks." (Courtesy Michael S. Clement, MD, Mesa, AZ.)

 

Angiomas are commonly referred to as vascular spiders.They are tiny, star-shaped or branched, slightly raised and pulsating end-arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders are bluish in color and do not blanch with pressure. Vascular spiders appear during the second to the fifth month of pregnancy in 65% of Caucasian women and 10% of African-American women. The spiders usually disappear after birth.

Pinkish red, diffuse mottling or well-defined blotches are seen over the palmar surfaces of the hands in approximately 60% of Caucasian women and 35% of African-American women during pregnancy (Cunningham et al., 2001). These color changes, called palmar erythema, are related primarily to increased estrogen levels.

Pruritus is a relatively common dermatologic symptom in pregnancy, with cholestasis of pregnancy being the most common cause of pruritic rash. The goal of management is to relieve the itching. Topical steroids are the usual treatment, although systemic steroids may be needed. The problem usually resolves in the postpartum period (Gordon & Landon, 1996).

Gum hypertrophy may occur. An epulis (gingival granuloma gravidarum) is a red, raised nodule on the gums that bleeds easily. This lesion may develop around the third month and usually continues to enlarge as pregnancy progresses. It is usually managed by avoiding trauma to the gums (e.g., using a soft toothbrush). An epulis usually regresses spontaneously after birth.

Nail growth may be accelerated. Some women may notice thinning and softening of the nails. Oily skin and acne vulgaris may occur during pregnancy. For some women the skin clears and looks radiant. Hirsutism, the excessive growth of hair or growth of hair in unusual places, is commonly reported. An increase in fine hair growth may occur but tends to disappear after pregnancy. However, growth of coarse or bristly hair does not usually disappear after pregnancy.

Increased blood supply to the skin leads to increased perspiration. Women feel hotter during pregnancy, possibly related to a progesterone-induced increase in body temperature and the increased BMR.

 

Musculoskeletal system

The gradually changing body and increasing weight of the pregnant woman cause noticeable alterations in her posture (Fig. 12) and the way she walks. The great abdominal distention that gives the pelvis a forward tilt, decreased abdominal muscle tone, and increased weight bearing require a realignment of the spinal curvature late in pregnancy. The woman's center of gravity shifts forward. An increase in the normal lumbosacral curve (lordosis) develops, and a compensatory curvature in the cervicodorsal region (exaggerated anterior flexion of the head) develops to help her maintain her balance. Aching, numbness, and weakness of the upper extremities may result. Large breasts and a stoop-shouldered stance will further accentuate the lumbar and dorsal curves. Walking is more difficult, and the waddling gait of the pregnant woman, called "the proud walk of pregnancy" by Shakespeare, is well known. The ligamentous and muscular structures of the middle and lower spine may be severely stressed. These and related changes often cause musculoskeletal discomfort, especially in older women or those with a back disorder or a faulty sense of balance.

 

 

Fig. 12 Postural changes during pregnancy. A, Nonpregnant. B, Incorrect posture during pregnancy. C, Correct posture during pregnancy.

 

Slight relaxation and increased mobility of the pelvic joints are normal during pregnancy. They are secondary to the exaggerated elasticity and softening of connective and collagen tissue caused by increased circulating steroid sex hormones, especially estrogen. Relaxin, an ovarian hormone, assists in this relaxation and softening. These adaptations permit enlargement of pelvic dimensions to facilitate labor and birth. The degree of relaxation varies, but considerable separation of the symphysis pubis and the instability of the sacroiliac joints may cause pain and difficulty in walking. Obesity and multifetal pregnancy tend to increase the pelvic instability. Peripheral joint laxity also increases as pregnancy progresses, but the cause is not known (Schauberger et al., 1996).

The muscles of the abdominal wall stretch and ultimately lose some tone. During the third trimester the rectus abdominis muscles may separate (Fig. 13), allowing abdominal contents to protrude at the midline. The umbilicus flattens or protrudes. After birth, the muscles gradually regain tone. However, separation of the muscles (diastasis recti abdominis) may persist.

 

Fig. 13 Possible change in rectus abdominis muscles during pregnancy. A, Normal position in nonpregnant woman. B, Diastasis recti abdominis in pregnant woman.

 

Neurologic system

Little is known regarding specific alterations in function of the neurologic system during pregnancy, aside from hypothalamic-pituitary neurohormonal changes. Specific physiologic alterations resulting from pregnancy may cause the following neurologic or neuromuscular symptoms:

• Compression of pelvic nerves or vascular stasis caused by enlargement of the uterus may result in sensory changes in the legs.

• Dorsolumbar lordosis may cause pain because of traction on nerves or compression of nerve roots.

• Edema involving the peripheral nerves may result in carpal tunnel syndrome during the last trimester. The syndrome is characterized by paresthesia (abnormal sensation such as burning or tingling) and pain in the hand, radiating to the elbow. The sensations are caused by edema that compresses the median nerve beneath the carpal ligament of the wrist. The dominant hand is usually affected most, although as many as 80% of women experience symptoms in both hands. Symptoms usually regress after pregnancy. In some cases, surgical treatment may be necessary (Cunningham et al., 2001).

• Acroesthesia (numbness and tingling of the hands) is caused by the stoop-shouldered stance (see Fig. 12, B) assumed by some women during pregnancy. The condition is associated with traction on segments of the brachial plexus.

• Tension headache is common when anxiety or uncertainty complicates pregnancy. However, vision problems, sinusitis, or migraine may also be responsible for headaches.

• Light-headedness, faintness, and even syncope (fainting) are common during early pregnancy. Vasomotor instability, postural hypotension, or hypoglycemia may be responsible.

• Hypocalcemia may cause neuromuscular problems such as muscle cramps or tetany.

 

Gastrointestinal system

Appetite. During pregnancy, the pregnant woman's appetite and food intake fluctuate. Early in pregnancy, some women experience "morning sickness" in response to increasing levels of hCG and altered carbohydrate metabolism (see Research box). Morning sickness refers to nausea with or without vomiting. It appears at approximately 4 to 6 weeks of gestation and usually subsides by the end of the third month (first trimester) of pregnancy. Severity varies from mild distaste for certain foods to more severe vomiting. The condition may be triggered by the sight or odor of various foods. Fatigue may also be responsible for severe nausea, but further research is needed to determine the role of this factor (O'Brien & Zhou, 1995). By the end of the second trimester, the appetite increases in response to increasing metabolic needs. Rarely does morning sickness have harmful effects on the embryo/fetus or the woman. Whenever the vomiting is severe or persists beyond the first trimester, or when it is accompanied by fever, pain, or weight loss, further evaluation is necessary and medical intervention is likely.

Women may also experience changes in their sense of taste, leading to cravings and changes in dietary intake. Some women have nonfood cravings (pica) such as ice, clay, and laundry starch (Cunningham et al., 2001).

 

RESEARCH ACUPRESSURE INTERVENTION FOR NAUSEA AND VOMITING OF PREGNANCY Up to 70% of all pregnant women experience nausea and vomiting of pregnancy (NVP), typically between weeks 5 through 12 of gestation.This may lead to nutritional deficits, dehydration, and electrolyte imbalances. Employment and family functioning may be affected. Pharmacologic treatment for NVP may cause teratogenic effects to the fetus. Nonpharmacologic treatments, including vitamin B6 (pyridoxine); acupressure; certain eating and drinking patterns; and vitamin, herbal, and homeopathic remedies, are not well researched. This clinical study investigated the use of acupressure as a treatment of NVR A total of 110 first-trimester pregnant women with NVP were randomly assigned to wearing Sea-Bands or placebo wrist bands. Sea-Bands are an acupressure device consisting of an elastic band worn at the wrist that holds a button against a point 3 fingerbreadths below the wrist crease and between the two flexor tendons on the medial forearm. The placebos had no button. Days 1 through 4, the women wore their Sea-Band or placebo, then removed them for days 5 through 7, keeping seven daily logs of nausea and vomiting. Results showed that the Sea-Band group had significantly less nausea and vomiting than the placebo group while wearing the device.The Sea-Band group also had a significant rise in nausea and vomiting after the device was discontinued. In addition, women in the Sea-Band group who used vitamin B6 during the treatment had significantly more relief from nausea and vomiting than did nontakers, but this effect disappeared when the device was removed. IMPLICATION FOR PRACTICE Alternative and complementary treatments for women's health, including pregnancy, are numerous. Nurses need to be informed about the most current treatments for discomforts of pregnancy that are effective and at the same time safe, noninvasive, and inexpensive. This study suggests that acupressure can be recommended for relief of NVR   Source: Steel, N. et al. (2001). Effect of acupressure by Sea-Bands on nausea and vomiting of pregnancy. J Obstet Gyncol Neonatal Nurs, 30(1), 61-70.

 

 

Mouth. The gums become hyperemic, spongy, and swollen during pregnancy. They tend to bleed easily because the rising levels of estrogen cause selective increased vascularity and connective tissue proliferation (a nonspecific gingivitis). Epulis (discussed in the section on the integumentary system) may develop at the gumline. Some pregnant women complain of ptyalism (excessive salivation), which may be caused by the decrease in unconscious swallowing by the woman when nauseated or from stimulation of salivary glands by eating starch (Cunningham et al., 2001).

Esophagus, stomach, and intestines. Herniation of the upper portion of the stomach (hiatal hernia) occurs after the seventh or eighth month of pregnancy in approximately 15% to 20% of pregnant women. This condition results from upward displacement of the stomach, which causes the hiatus of the diaphragm to widen. It occurs more often in multiparas and older or obese women.

Increased estrogen production causes decreased secretion of hydrochloric acid. Therefore peptic ulcer formation or flare-up of existing peptic ulcers is uncommon during pregnancy.

Increased progesterone production causes decreased tone and motility of smooth muscles, resulting in esophageal regurgitation, slower emptying time of the stomach, and reverse peristalsis. As a result, the woman may experience "acid indigestion" or heartburn (pyrosis).

Iron is absorbed more readily in the small intestine in response to increased needs during pregnancy. Even when the woman is deficient in iron, it will continue to be absorbed in sufficient amounts for the fetus to have a normal hemoglobin level.

Increased progesterone (causing loss of muscle tone and decreased peristalsis) results in an increase in water absorption from the colon and may cause constipation. Constipation can also result from hypoperistalsis (sluggishness of the bowel), food choices, lack of fluids, iron supplementation, decreased activity level, abdominal distention by the pregnant uterus, and displacement and compression of the intestines. If the pregnant woman has hemorrhoids (see Fig. 9) and is constipated, the hemorrhoids may become everted or may bleed during straining at stool. A mild ileus (sluggishness and lack of movement resulting in obstruction) that follows birth, as well as postbirth fluid loss and perineal discomfort, contributes to continuing constipation.

Gallbladder and liver. The gallbladder is often distended because of its decreased muscle tone during pregnancy. Increased emptying time and thickening of bile caused by prolonged retention are typical changes. These features, together with slight hypercholesterolemia from increased progesterone levels, may account for the development of gallstones during pregnancy.

Hepatic function is difficult to appraise during pregnancy. However, only minor changes in liver function develop. Occasionally, intrahepatic cholestasis (retention and accumulation of bile in the liver, caused by factors within the liver) occurs late in pregnancy in response to placental steroids and may result in pruritus gravidarum (severe itching) with or without jaundice. These distressing symptoms subside soon after birth.

Abdominal discomfort. Intraabdominal alterations that can cause discomfort include pelvic heaviness or pressure, round ligament tension, flatulence, distention and bowel cramping, and uterine contractions. In addition to displacement of intestines, pressure from the expanding uterus causes an increase in venous pressure in the pelvic organs. Although most abdominal discomfort is a consequence of normal maternal alterations, the health care provider must be constantly alert to the possibility of disorders such as bowel obstruction or an inflammatory process.

Appendicitis may be difficult to diagnose in pregnancy because the appendix is displaced upward and laterally, high and to the right, away from McBurney's point (Fig. 14).

 

Fig. 14 Change in position of appendix in pregnancy. Note McBurney's point.

 

Endocrine system

Profound endocrine changes are essential for pregnancy maintenance, normal fetal growth, and postpartum recovery.

Pituitary and placental hormones. During pregnancy, the elevated levels of estrogen and progesterone (produced first by the corpus luteum in the ovary until approximately 14 weeks of gestation and then by the placenta) suppress secretion of follicle-stimulating hormone and luteinizing hormone by the anterior pituitary. The maturation of a follicle and ovulation do not occur. Although the majority of women experience amenorrhea (absence of menses), at least 20% have some slight, painless spotting during early gestation. Implantation bleeding and bleeding following intercourse related to cervical friability can occur. Most of the women experiencing slight gestational bleeding continue to full term and have normal infants. However, all instances of bleeding should be reported and evaluated.

After implantation, the fertilized ovum and the chorionic villi produce hCG, which maintains the corpus luteum's production of estrogen and progesterone until the placenta takes over their production (Creasy & Resnik, 1999).

Progesterone is essential for maintaining pregnancy by relaxing smooth muscles, resulting in decreased uterine contractility and prevention of miscarriage. Progesterone and estrogen cause fat to deposit in subcutaneous tissues over the maternal abdomen, back, and upper thighs. This fat serves as an energy reserve for both pregnancy and lactation. Estrogen also promotes the enlargement of the genitals, uterus, and breasts and increases vascularity, causing vasodilation. Estrogen causes relaxation of pelvic ligaments and joints. It also alters metabolism of nutrients by interfering with folic acid metabolism, increasing the level of total body proteins, and promoting retention of sodium and water by kidney tubules. Estrogen may decrease secretion of hydrochloric acid and pepsin, which may be responsible for digestive upsets such as nausea.

Serum prolactin produced by the anterior pituitary begins to rise early in the first trimester and increases progressively to term. It is responsible for initial lactation; however, the high levels of estrogen and progesterone inhibit lactation by blocking the binding of prolactin to breast tissue until after birth (Guyton & Hall, 1997).

Oxytocin is produced by the posterior pituitary in increasing amounts as the fetus matures. This hormone can stimulate uterine contractions during pregnancy, but high levels of progesterone prevent contractions until near term. Oxytocin also stimulates the let-down or milk-ejection reflex after birth in response to the infant sucking at the mother's breast.

Human chorionic somatomammotropin (hCS), previously called human placental lactogen, is produced by the placenta, acts as a growth hormone, and contributes to breast development. It decreases the maternal metabolism of glucose and increases the amount of fatty acids for metabolic needs (Alsat et al., 1997; Guyton & Hall, 1997).

Thyroid gland. During pregnancy there is an increase in gland activity and hormone production. The increased activity is reflected in a moderate enlargement of the thyroid gland caused by hyperplasia of the glandular tissue and increased vascularity (Cunningham et al., 2001). Thyroxine-binding globulin increases as a result of increased estrogen levels. This increase begins at approximately 20 weeks of gestation. The level of total (free and bound) thyroxine (T4) increases between 6 and 9 weeks of gestation and plateaus at 18 weeks of gestation. Free T4 and free triiodothyronine (T3) return to nonpregnant levels after the first trimester. Despite these changes in hormone production, the pregnant woman usually does not develop hyperthyroidism (Cunningham et al., 2001).

Parathyroid gland. Parathyroid hormone controls calcium and magnesium metabolism. Pregnancy induces a slight hyperparathyroidism, a reflection of increased fetal requirements for calcium and vitamin D. The peak level of parathyroid hormone occurs between 15 and 35 weeks of gestation when the needs for growth of the fetal skeleton are greatest. Levels return to normal after birth.

Pancreas. The fetus requires significant amounts of glucose for its growth and development. To meet its need for fuel, the fetus not only depletes the store of maternal glucose but also decreases the mother's ability to synthesize glucose by siphoning off her amino acids. Maternal blood glucose levels fall. Maternal insulin does not cross the placenta to the fetus. As a result, in early pregnancy, the pancreas decreases its production of insulin.

As pregnancy continues, the placenta grows and produces progressively larger amounts of hormones (i.e., hCS, estrogen, and progesterone). Cortisol production by the adrenals also increases. Estrogen, progesterone, hCS, and cortisol collectively decrease the mother's ability to use insulin. Cortisol stimulates increased production of insulin but also increases the mother's peripheral resistance to insulin (i.e., the tissues cannot use the insulin). Decreasing the mother's ability to use her own insulin is a protective mechanism that ensures an ample supply of glucose for the needs of the fetoplacental unit. The result is an added demand for insulin by the mother that continues to increase at a steady rate until term. The normal beta cells of the islets of Langerhans in the pancreas can meet this demand for insulin.

Adrenal glands. The adrenal glands change little during pregnancy. Secretion of aldosterone is increased, resulting in reabsorption of excess sodium from the renal tubules. Cortisol levels are also increased (Chamberlain & Pipkin, 1998).

Nursing Care During Pregnancy

 

The prenatal period is a time of physical and psychologic preparation for birth and parenthood. Becoming a parent is a time of intense learning both for par­ents and for those close to them. The prenatal period provides  a unique  opportunity for nurses  and  other members of the health care team to influence family health. During this period, essentially healthy women seek regular care and guidance. The nurse's health pro­motion interventions can affect the well-being of the woman, her unborn child, and the rest of her family for many years.

Regular prenatal visits, ideally beginning soon after the first missed menstrual period, offer opportunities to en­sure the health of the expectant mother and her infant. Prenatal health care permits diagnosis and treatment of maternal disorders that may have preexisted or may de­velop during the pregnancy. Care is designed to monitor the growth and development of the fetus and to identify abnormalities that may interfere with the course of normal labor. The woman and her family can seek support for stress and learn parenting skills.

Pregnancy lasts 9 calendar months, but health care providers use the concept of lunar months, which last 28 days, or 4 weeks. Thus normal pregnancy lasts approxi­mately 10 lunar months, or 40 weeks. Health care providers also refer to early, middle, and late pregnancy as trimesters. The first trimester lasts from weeks 1 through 13; the sec­ond, from weeks 14 through 26; and the third, from weeks 27 through 40. A pregnancy is considered at term if it ad­vances to 38 to 40 weeks. The focus of this chapter is on meeting the health needs of the expectant family over the course of pregnancy, which is known as the prenatal period.

DIAGNOSIS OF PREGNANCY

Women may suspect pregnancy when they miss a menstrual period. Many women come to the first prenatal visit after a positive home pregnancy test. However, the clinical diagno­sis of pregnancy before the second missed period may be difficult in some women. Physical variability, lack of relax­ation, obesity, or tumors, for example, may confound even the experienced obstetrician or midwife. Accuracy is impor­tant, however, because emotional, social, medical, or legal consequences of an inaccurate diagnosis, either positive or negative, can be extremely serious. A correct date for the last (normal) menstrual period (LMP), the date of intercourse, and a basal body temperature record may be of great value in the accurate diagnosis of pregnancy.

 

SIGNS AND SYMPTOMS

Great variability is possible in the subjective and objective symptoms of pregnancy. Therefore the diagnosis of preg­nancy may be uncertain for a time. Many of the indicators of pregnancy are clinically useful in the diagnosis of preg­nancy, and they are classified as presumptive, probable, or positive (see Table 8-2).

 

ESTIMATING DATE OF BIRTH

Following the diagnosis of pregnancy, the woman's first question usually concerns when she will give birth. This date has traditionally been termed the estimated date of confinement (EDC). To promote a more positive percep­tion of both pregnancy and birth, however, the term esti­mated date of birth (EDB) is usually used. Because the pre­cise date of conception generally is unknown, several formulas or rules of thumb have been suggested for cal­culating the EDB. None of these guides are infallible, but

Nagele's rule is reasonably accurate and is the method usually used.

Nagele's rule is as follows: add 7 days to the first day of the LMP, subtract 3 months, and add 1 year. For exam­ple, if the first day of the LMP was July 10, 2002, the EDB is April 17, 2003. In simple terms, add 7 days to the LMP and count forward 9 months. Nagele's rule assumes that the woman has a 28-day cycle and that the pregnancy oc­curred on the fourteenth day. An adjustment is in order if the cycle is longer or shorter than 28 days. Approximately 4% to 10% of pregnant women give birth spontaneously on the EDB; however, most women give birth during the period extending from 7 days before to 7 days after the EDB.

ADAPTATION TO PREGNANCY

Pregnancy affects all family members, and each family member must adapt to the pregnancy and interpret its meaning in light of his or her own needs. This process of family adaptation to pregnancy takes place within a cul­tural environment that is influenced by societal trends.

 

MATERNAL ADAPTATION

Women of all ages use the months of pregnancy to adapt to the maternal role, a complex process of social and cog­nitive learning. Early in pregnancy nothing seems to be happening, and much time is spent sleeping. With the per­ception of fetal movement in the second trimester, the woman turns attention inward to her pregnancy.

Pregnancy is a maturational milestone that can be stress­ful but rewarding as the woman prepares for a new level of caring and responsibility. Her self-concept changes in readi­ness for parenthood as she prepares for her new role. Grad­ually, she moves from being self-contained and indepen­dent to being committed to a lifelong concern for another human being. This growth requires mastery of certain de­velopmental tasks: accepting the pregnancy, identifying with the role of mother, reordering the relationships be­tween herself and her mother and between herself and her partner, establishing a relationship with the unborn child, and preparing for the birth experience (Lederman, 1996). The partner's emotional support is an important factor in the successful accomplishment of these developmental tasks. Single women with limited support may have diffi­culty making this adaptation.

 

Accepting the pregnancy

The first step in adapting to the maternal role is accept­ing the idea of pregnancy and assimilating the pregnant state into the woman's way of life (Mercer, 1995). The de­gree of acceptance is reflected in the woman's readiness for pregnancy and her emotional responses.

Initially, many women are dismayed at finding them­selves pregnant. Eventual acceptance of pregnancy paral­lels the growing acceptance  of the reality of a child. Nonacceptance of the pregnancy should not be equated with rejection of the child. A woman may dislike being pregnant but feel love for the child to be born. Women who are happy and pleased about their pregnancy often view it as biologic fulfillment and part of their life plan. They have high self-esteem and tend to be confident about outcomes for themselves, their babies, and other family members. Many women are surprised to experience emotional la­bility, or rapid and unpredictable changes in mood. In­creased irritability, explosions of tears and anger, and feel­ings of great joy and cheerfulness are expressed with little or no apparent provocation.

Most women experience ambivalent feelings during pregnancy. Ambivalence, having conflicting feelings simul­taneously, is considered a normal response for people preparing for a new role. Even women who are pleased to be pregnant may experience feelings of hostility toward the pregnancy or unborn child from time to time. Intense feelings of ambivalence that persist through the third trimester may indicate an unresolved conflict with the motherhood role (Mercer, 1995). After the birth of a healthy child, memories of these ambivalent feelings usu­ally are dismissed. If the child is born with a defect, how­ever, a woman may look back at the times when she did not want the child and feel intensely guilty. She may be­lieve that her ambivalence caused the birth defect. She will need reassurance that her feelings were not responsible for the problem.

Identifying with the mother role

The process of identifying with the mother role begins early in each woman's life at the time she is being moth­ered as a child. Her social group's perception of what con­stitutes the feminine role can subsequently influence her toward choosing between motherhood or a career, being married or single, or being independent rather than inter­dependent. Practice roles, such as playing with dolls, baby­sitting, and taking care of siblings, may increase her un­derstanding of what being a mother entails.

Many women have always wanted a baby, liked children, and looked forward to motherhood. Their high motivation to become a parent promotes acceptance of pregnancy and eventual prenatal and parental adaptation. Other women apparently have not considered in any detail what mother­hood means to them. During pregnancy, conflicts such as not wanting the pregnancy and child-related or career-related decisions need to be resolved.

 

Reordering personal relationships

Close relationships held by the pregnant woman un­dergo change during pregnancy as she prepares emotion­ally for the new role of mother. As family members learn their new roles, periods of tension and conflict may occur. An understanding of the typical patterns of adjustment can help the nurse to reassure the pregnant woman and explore issues related to social support. Promoting effective communication patterns between the expectant mother and her own mother and between the expectant mother and her partner are common nursing interventions provided during the prenatal visits.

The woman's relationship with her mother is significant in adaptation to pregnancy and motherhood. Important components in the pregnant woman's relationship with her mother are the mother's availability (past and present), her reactions to the daughter's pregnancy, respect for her daughter's autonomy, and the willingness to reminisce (Mercer, 1995).

The mother's reaction to the daughter's pregnancy sig­nifies her acceptance of the grandchild and of her daugh­ter. If the mother is supportive, the daughter has an op­portunity to discuss pregnancy and labor and her feelings of joy or ambivalence with a knowledgeable and accepting woman (Fig. 1). Rubin (1975) noted that if the pregnant woman's mother is not pleased with the pregnancy, the daughter begins to have doubts about her self-worth and the eventual acceptance of her child by others. Reminisc­ing about the pregnant woman's early childhood and shar­ing the grandmother-to-be's account of her childbirth ex­perience help the daughter anticipate and prepare for labor and birth.

Fig. 1 A pregnant woman and her mother enjoying their walk together. (Courtesy Michael S. Clement, MD, Mesa, AZ.)

 

Although the woman's relationship with her mother is significant in considering her adaptation in pregnancy, the most important person to the pregnant woman is usually the father of her child. A woman who is nurtured by her partner during pregnancy has fewer emotional and physical symptoms, fewer labor and childbirth complications, and an easier postpartum adjustment.

The marital or committed relationship is not static but evolves over time. The addition of a child changes forever the nature of the bond between partners. Partners who trust and support each other are able to share mutual-dependency needs (Mercer, 1995).

Sexual expression during pregnancy is highly individ­ual. The sexual relationship is affected by physical, emo­tional, and interactional factors, including myths about sex during pregnancy, sexual dysfunction, and physical changes in the woman. As pregnancy progresses, changes in body shape, body image, and levels of discomfort in­fluence both partners' desire for sexual expression. During the first trimester the woman's sexual desire may decrease, especially if she experiences breast tenderness, nausea, fa­tigue, or sleepiness (von Sydow, 1999). As she progresses into the second trimester, however, her sense of well-being combined with the increased pelvic congestion that occurs at this time may increase her desire for sexual release. In the third trimester, somatic complaints and physical bulkiness may increase her physical discomfort and diminish her interest in sex. Nurses can facilitate communication between partners by talking to expectant couples about possible changes in feelings and behaviors they may expe­rience as pregnancy progresses (Ramer & Frank, 2001).

 

Establishing a relationship with the fetus

Emotional attachment to the child begins during the prenatal period as women use fantasizing and daydream­ing to prepare themselves for motherhood (Rubin, 1975). They think of themselves as mothers and imagine mater­nal qualities they would like to possess. Expectant parents desire to be warm, loving, and close to their child. They try to anticipate changes in their lives that the child will bring and wonder how they will react to noise, disorder, less freedom, and caregiving activities. The mother-child rela­tionship progresses through pregnancy as a developmental process. Three phases in the developmental pattern be­come apparent.

In phase 1 the woman accepts the biologic fact of preg­nancy. She needs to be able to state, "I am pregnant." In phase 2 the woman accepts the growing fetus as distinct from herself and as a person to nurture. She can now say, "I am going to have a baby." This usually occurs by the fifth month. With acceptance of the reality of the child (hearing the heartbeat and feeling the child move) and an overall feeling of well-being, the woman enters a quiet pe­riod and becomes more introspective. A fantasy child be­comes precious to the woman. As the woman seems to withdraw and to concentrate her interest on the unborn child, her partner and children can feel left out.

During phase 3 of the attachment process, the woman prepares realistically for the birth and parenting of the child. She expresses the thought "I am going to be a mother" and defines the nature and characteristics of the child. She may, for example, speculate about the child's sex and personality traits based on patterns of fetal activity.

Although the mother alone experiences the child within, both parents and siblings believe the unborn child responds in a highly individualized, personal manner. Family members may interact a great deal with the unborn child by talking to the fetus and stroking the mother's ab­domen, especially when the fetus shifts position (Fig. 2).

 

Fig. 2 Sibling feeling movement of fetus. (Courtesy Kim Molloy, Knoxville, IA.)

 

Preparing for childbirth

Many women actively prepare for birth. They read books, view films, attend parenting classes, and talk to other women. They seek the best caregiver possible for ad­vice, monitoring, and caring (Lederman, 1996). The multi-para has her own history of labor and birth, which influ­ences her approach to preparation for this childbirth experience.

Anxiety can arise from concern about a safe passage for herself and her child during the birth process (Mercer, 1995; Rubin, 1975). These feelings persist despite statistical evidence about the safe outcome of pregnancy for moth­ers and their infants. Many women fear the pain of child­birth or mutilation because they do not understand anatomy and the birth process. Education can alleviate many of these fears.

Toward the end of the third trimester, breathing is dif­ficult and movements of the fetus become vigorous enough to disturb the mother's sleep. Backaches, fre­quency and urgency of urination, constipation, and vari­cose veins can become troublesome. The bulkiness and awkwardness of her body interfere with the woman's abil­ity to care for other children, perform routine work-related duties, and assume a comfortable position for sleep and rest. By this time most women become impatient for labor to begin, whether the birth is anticipated with joy, dread, or a mixture of both. A strong desire to see the end of pregnancy, to be over and done with it, makes women at this stage ready to move on to childbirth.

 

PATERNAL ADAPTATION

The father's beliefs and feelings about the ideal mother and father and his cultural expectation of appropriate be­havior during pregnancy affect his response to his part­ner's need for him. For most men, pregnancy can be a time of preparation for the parental role with intense learning.

 

Accepting the pregnancy

In Western societies the participation of fathers in child­birth has risen dramatically over the past 25 years, and the father in the role of labor coach is common. The man's emotional responses to becoming a father, his concerns, and his informational needs change during the course of pregnancy. May (1982) described three phases characteriz­ing the three developmental tasks experienced by the ex­pectant father:

* The early period, the announcement phase, may last from a few hours to a few weeks. The developmental task is to accept the biologic fact of pregnancy. Men react to the confirmation of pregnancy with joy or dismay, depending on whether the pregnancy is desired or unplanned or unwanted. Some expectant fathers report having nausea and other gastrointestinal symptoms, fatigue, and other physical discomforts. This phenomenon of men experi­encing pregnancy-like symptoms is known as the couvade syndrome.

* The second phase, the moratorium phase, is the period when he adjusts to the reality of pregnancy. The devel­ opmental task is to accept the pregnancy. Men appear to put conscious thought of the pregnancy aside for a time. They become more introspective and engage in many discussions  about  their philosophy  of life,   religion, childbearing, and child-rearing practices and their rela­ tionships with family members and friends. Depending on the man's readiness for the pregnancy, this phase may be relatively short or persist until the last trimester.

* The third phase, the focusing phase, begins in the last trimester and is characterized by the father's active in­ volvement in both the pregnancy and his relationship with his child. The developmental task is to negtiate ith his partner the role he is to play in labor and to pre­pare for parenthood. In this phase the man concentrates on his experience of the pregnancy and begins to think of himself as a father.

 

Identifying with the father role

Each father brings to pregnancy attitudes that affect the way in which he adjusts to the pregnancy and parental role. Some men are highly motivated to nurture and love a child. They may be excited and pleased about the antic­ipated role of father. Others may be more detached or even hostile to the idea of fatherhood.

 

Reordering personal relationships

The partner's main role in pregnancy is to nurture and respond to the pregnant woman's feelings of vulnerability. Some aspects of a partner's behavior may indicate rivalry. Direct rivalry with the fetus may be evident, especially dur­ing sexual activity. Men may protest that fetal movements prevent sexual gratification or that they are being watched by the fetus during sexual activity.

The woman's increased introspection may cause her partner to feel uneasy as she becomes preoccupied with thoughts of the child and of her motherhood, with her growing dependence on her physician or midwife, and with her reevaluation of the couple's relationship.

 

Establishing a relationship with the fetus

The father-child attachment can be as strong as the mother-child relationship, and fathers can be as competent as mothers in nurturing their infants. The father-child at­tachment also begins during pregnancy. A father may rub or kiss the maternal abdomen, try to listen to the fetus, or play with the fetus as he notes fetal movement.

Men prepare for fatherhood in many of the same ways as women do for motherhood—by reading, fantasizing, and daydreaming about the baby. As the birth day ap­proaches, fathers have more questions about fetal and newborn behaviors. Some fathers are shocked or amazed at the size of the clothes and furniture for the baby.

 

Preparing for childbirth

The days and weeks immediately before the expected day of birth are characterized by anticipation and anxiety. Boredom and restlessness are common as the couple fo­cuses on the birth process. The father's major concerns are getting the mother to a medical facility in time for the birth and not appearing ignorant. He may fantasize dif­ferent situations and plan what he will do in response to them, or he may rehearse taking various routes to the hos­pital, timing each route at different times of the day. Many fathers have fears concerning safe passage of his partner and the mutilation and death of his partner and child.

With the exception of childbirth preparation classes, a father has few opportunities to learn ways to be an in­volved and active partner in this rite of passage into par­enthood. The tensions and apprehensions of the unpre­pared, unsupportive father are readily transmitted to the mother and may increase her fears.

 

SIBLING ADAPTATION

Sharing the spotlight with a new brother or sister may be the first major challenge for a child. The older child often experiences a sense of loss or feels jealous at being "re­placed" by the new sibling. Some of the factors that influ­ence the child's response are age, the parents' attitudes, the role of the father, the length of separation from the mother, the hospital's visitation policy, and the way the child has been prepared for the change (Wright & Leahy, 2000).

The mother with other children must devote time and ef­fort to reorganizing her relationships with these children. She needs to prepare siblings for the birth of the child (Fig. 3 and Box 1) and begin the process of role transition in the family by including the children in the pregnancy and being sympathetic to older children's protests against losing their places in the family hierarchy. No child willingly gives up a familiar position.

Fig. 3 Sibling class of preschoolers learning infant care using dolls. (Courtesy Michael S. Clement, MD, Mesa, AZ.)

 

Box 9 Tips for Sibling Preparation PRENATAL 1. Take your child on a prenatal visit. Let the child listen to the fetal heartbeat and feel the baby move. 2. Involve the child in preparations for the baby, such as helping decorate the baby's room. 3. Move the child to a bed (if still sleeping in a crib) at least 2 months before the baby is due. 4. Read books, show videos, and/or take child to sibling preparation classes, including a hospital tour. 5. Answer your child's questions about the coming birth, what babies are like, and any other questions. 6. Take your child to the homes of friends who have babies so that the child has realistic expectations of what babies are like.   DURING THE HOSPITAL STAY 1. Have someone bring the child to the hospital to visit you and the baby (unless you plan to have the child at­ tend the birth). 2. Do not force interactions between the child and the baby. Often the child will be more interested in seeing you and being reassured of your love. 3. Help the child explore the infant by showing how and where to touch the baby. 4. Give the child a gift (from you or you, the father, and b y).   GOING HOME 1. Leave the child at home with a relative or baby-sitter. 2. Have someone else carry the baby from the car so that you can hug the child first.   ADJUSTMENT AFTER THE BABY IS HOME 1. Arrange for a special time with the child alone with each parent. 2. Do not exclude the child during infant feeding times.The child can sit with you and the baby and feed a doll or drink juice or milk with you or sit quietly with a game. 3. Prepare small gifts for the child so that when the baby gets gifts, the sibling won't feel left out. The child can also help open the baby gifts. 4. Praise the child for acting age appropriately (so that being a baby does not seem better than being older).

 

Siblings' responses to pregnancy vary with their age and dependency needs. The 1-year-old infant seems largely un­aware of the process, but the 2-year-old child notices the change in his or her mother's appearance and may com­ment that "Mommy's fat." The 2-year-old child's need for sameness in the environment makes the child aware of any change. Toddlers may exhibit more "clinging" behavior and revert to dependent behaviors in toilet training or eating.

By the third or fourth year of age, children like to be told the story of their own beginning and accept its being compared with the present pregnancy. They like to listen to heartbeats and feel the baby moving in utero. Some­times they worry about how the baby is being fed and what it wears.

School-age children take a more clinical interest in their mother's pregnancy. They may want to know in more de­tail, "How did the baby get in there?" and "How will it get out?" Children in this age-group notice pregnant women in stores, churches, and schools and sometimes seem shy if they need to approach a pregnant woman directly. On the whole they look forward to the new baby, see themselves as "mothers" or "fathers," and enjoy buying baby supplies and readying a place for the baby. Because they still think in concrete terms and base judgments on the here and now, they respond positively to their mother's current good health.

Early and middle adolescents preoccupied with the es­tablishment of their own sexual identity may have diffi­culty accepting the overwhelming evidence of the sexual activity of their parents. They reason that if they are too young for such activity, certainly their parents are too old. They seem to take on a critical parental role and may ask, "What will people think?" or "How can you let yourself get so fat?" Many pregnant women with teenage children will confess that the attitudes of their teenagers are the most difficult aspect in their current pregnancy.

Late adolescents do not appear to be unduly disturbed. They realize that they soon will be gone from home. Par­ents usually report that they are comforting and act more as other adults than as children.

 

GRANDPARENT ADAPTATION

Every pregnancy affects all family relationships. For ex­pectant grandparents, a first pregnancy in a child is unde­niable evidence that they are growing older. Many think of a grandparent as old, white-haired, and becoming feeble of mind and body; however, some people face grandparent-hood while still in their thirties or forties. A mother-to-be announcing her pregnancy to her mother may be greeted by a negative response that indicates that she is not ready to be a grandmother. Both daughter and mother may be startled and hurt by the response.

Some expectant grandparents not only are nonsupport-ive but also use subtle means to decrease the self-esteem of the young parents-to-be. Mothers may talk about their ter­rible pregnancies; fathers may discuss the endless cost of rearing children; and mothers-in-law may complain that their sons are neglecting them because their concern is now directed toward the pregnant daughters-in-law.

However, most grandparents are delighted at the prospect of a new baby in the family. It reawakens the feel­ings of their own youth, the excitement of giving birth, and their delight in the behavior of the parents-to-be when they were infants. They set up a memory store of the child's first smiles, first words, and first steps, which they can use later for "claiming" the newborn as a member of the family. Their and the parents' satisfaction comes with the realization that the continuity between past and pre­sent is guaranteed.

In addition, the grandparent is the historian who trans­mits the family history, a resource person who shares knowledge based on experience; a role model; and a sup­port person. The grandparent's presence and support can strengthen family systems by widening the circle of sup­port and nurturance (Fig. 4).

 

Fig. 4 Grandfather getting to know grandson. (Cour­tesy Sharon Johnson, Petaluma, CA.)

 

Expectant grandparenthood also can represent a matu-rational crisis for the parent of an expectant parent. To be truly family oriented, maternity care must include the grandparent in the implementation of the nursing process with childbearing families. A class for grandparents is one method of incorporating the grandparents into the family system and encouraging communication between the gen­erations (Nichols & Humenick, 2000).

CARE MANAGEMENT

Prenatal care is ideally a multidisciplinary activity in which nurses work with physicians or midwives, nutritionists, social workers, and others. Collaboration among these indi­viduals is necessary to provide holistic care. The case man­agement model, which makes use of care maps and critical pathways, is one system that promotes comprehensive care with limited overlap in services. To emphasize the nursing role, care management here is organized around the cen­tral elements of the nursing process: assessment, nursing diagnoses, expected outcomes, plan of care and interven­tions, and evaluation.

 

Assessment and Nursing Diagnoses

Once the presence of pregnancy has been confirmed and the woman's desire to continue the pregnancy has been val­idated, prenatal care is begun. The assessment process be­gins at the initial prenatal visit and is continued through­out the pregnancy. Assessment techniques include the interview, physical examination, and laboratory tests. Be­cause the initial visit and follow-up visits are distinctly dif­ferent in content and process, they are described separately.

Initial Visit

The pregnant woman and family members who may be present should be told that the first prenatal visit is more lengthy and in-depth than future visits. The initial evalua­tion includes a comprehensive health history emphasizing the current pregnancy, previous pregnancies, the family, nutritional status, a psychosocial profile, a physical assess­ment, diagnostic testing, and an overall risk assessment. A prenatal history form is the best way to document infor­mation obtained (Fig. 5).

 

 

 

 

Fig. 5 Sample prenatal history form. (From American College of Obstetricians and Gynecologists. [1997]. Antepartum record. Washington, DC: ACOG. To order this publication, call 800-

762-2264.)

 

Interview. The therapeutic relationship between the nurse and the woman is established during the initial as­sessment interview. It is a time for planned, purposeful communication that focuses on specific content. The data collected are of two types: the woman's subjective ap­praisal of her health status and the nurse's objective ob­servations of the woman's affect, posture, body language, skin color, and other physical and emotional signs. Special needs are noted at this time (e.g., wheelchair access, assistance in getting on and off the examining table, cognitive deficits).

Often, the pregnant woman is accompanied by one or more family members. The nurse needs to build a rela­tionship with these people as part of the social context of the patient. In addition, family members help recal and validate information related to the woman's health. With her permission, those accompanying the woman can be included in the initial prenatal interview, and the observations and information about the woman's family form part of the database. For example, if the woman is accompanied by small children, the nurse can ask about her plans for child care during the time of labor and birth.

Reason for seeking care. Although pregnant women are scheduled for "routine" prenatal visits, they often come to the health care provider seeking information or reassurance about a particular concern. When the patient is asked a broad,

Current pregnancy. The presumptive signs of preg­nancy may be of great concern to the woman. A review of symptoms she is experiencing, and how she is coping with them, helps establish a database to develop a plan of care. Some early teaching about managing uncomfortable symptoms may be provided at this time.

Obstetric/gynecologic history. Data are gathered on the woman's age at menarche, menstrual history, and con­traceptive history; the nature of any infertility or gyneco­logic conditions (e.g., fibroids); history of any sexually transmitted infections (STIs); sexual history; and the his­tory of all her pregnancies, including the present preg­nancy, and their outcomes. The date and findings of her most recent Papanicolaou test before this pregnancy are noted. The date of her LMP is obtained to establish the EDB.

Medical history. The medical history includes those medical or surgical conditions that may affect the preg­nancy or that may be affected by the pregnancy. For ex­ample, a pregnant woman who has diabetes or epilepsy re­quires special care. Because most women are anxious during the initial interview, the nurse's reference to cues, such as a Medic-Alert bracelet, prompts the woman to ex­plain allergies, chronic diseases, or medications being taken (e.g., cortisone, insulin, anticonvulsants).

The nature of previous surgical procedures should also be described. If a woman has undergone uterine surgery or extensive repair of the pelvic floor, a cesarean birth may be necessary; appendectomy rules out appendicitis as a cause of right lower quadrant pain; spinal surgery may con-traindicate the use of spinal or epidural anesthesia. Any in­jury involving the pelvis is noted.

Many women who have chronic or handicapping condi­tions forget to mention them during the initial assessment Because they have become so adapted to them. Special shoes or a limp may indicate the existence of a pelvic struc­tural defect, which is an important consideration in preg­nant women. The nurse who observes these special charac­teristics and inquires about them sensitively can obtain individualized data that will provide the basis for a compre­hensive nursing care plan. Observations are vital compo­nents of the interview process because they prompt the nurse and woman to focus on the specific needs of the woman and her family.

Nutritional history. The woman's nutritional history is an important component of the prenatal history because her nutritional status has a direct effect on the growth and development of the fetus (e.g., adequate folic acid intake before pregnancy can prevent neural tube defects). A di­etary assessment can reveal special diet practices, food al­lergies, eating behaviors, and other factors related to her nutritional status. Pregnant women are usually motivated to learn about good nutrition and respond well to the feed­back regarding good nutrition generated by this assessment.

History of drug and herbal therapy use. A woman's past and present use of legal (e.g., over-the-counter [OTC], prescription, caffeine, alcohol, nicotine) and illegal (e.g., marijuana, cocaine, heroin) drugs and herbal preparations

must be assessed because many substances cross the pla­centa and may therefore harm the developing fetus. Peri­odic urine toxicology screening tests are often recom­mended during the pregnancies of women who have a history of illegal drug use.

 

LEGAL TIP       Drug Screening in Pregnancy

Pregnant women in all states of the United States must give consent before screening for drug use can be done (Gottlieb, 2001).

 

Family history. The family history provides informa­tion about the woman's immediate family, including par­ents, siblings, and children. These data help identify fa­milial or genetic disorders or conditions that could affect the present health status of the woman or her fetus.

Social and experiential history. Situational factors such as the family's ethnic and cultural background and so-cioeconomic status are assessed. The following information may be obtained over several encounters. The woman's perception of this pregnancy is explored by asking her such questions as the following: Is this pregnancy wanted or not, planned or not? Is the woman pleased, displeased, accept­ing, or nonaccepting? What problems may arise because of the pregnancy: financial, career, and living accommoda­tions? The social support system is determined by asking her such questions as the following: What primary support is available to her? Are changes needed to promote ade­quate support? What are the existing relationships among the mother, father/partner, siblings, and in-laws? What preparations are being made for her care and that of de­pendent family members during labor and for the care of the infant after birth? Is community support needed, for example, financial or educational?

What are the woman's ideas about childbearing, her ex­pectations of the infant's behavior, and her outlook on life and the female role? Other such questions that need to be asked include: What does the woman think it will be like to have a baby in the home? How is her life going to change by having a baby? What plans does having a baby interrupt? During interviews throughout the pregnancy the nurse should remain alert to the appearance of poten­tial parenting problems, such as depression, lack of family support, and inadequate living conditions. The nurse needs to assess what the woman's attitude toward health care is, particularly during childbearing; what she expects of the health care provider; and her view of the relation­ship between the woman and nurse.

Coping mechanisms and patterns of interacting are also identified. Early in the pregnancy the nurse should deter­mine the woman's knowledge of pregnancy; maternal changes; fetal growth; self-care; and care of the newborn, including feeding. Asking about attitudes toward unmed-icated or medicated childbirth and about her knowledge of the availability of parenting skills classes is important. Be­fore planning for nursing care the nurse needs information

Attitudes concerning the range of acceptable sexual be­havior during pregnancy should also be explored by asking questions such as the following: What has your family (partner, friends) told you about sex during pregnancy? The woman's sexual self-concept is given more emphasis by asking questions such as the following: How do you feel about the changes in your appearance? How does your partner feel about your body now? How do you feel wear­ing maternity clothes?

History of physical abuse. All women should be as­sessed for a history or risk of physical abuse, particularly because the likelihood of abuse increases during preg­nancy (see Guidelines/Guias box). Although visual cues from the woman's appearance or behavior may suggest the possibility, if questioning is limited to those women who fit the supposed profile of the battered woman, many women will be missed. Identification of abuse and immediate clinical intervention that includes information about safety can result in behaviors that may prevent future abuse and increase the safety and well-being of the woman and her infant (McFarlane, Parker, & Cross, 2001).

During pregnancy, the target body parts change during abusive episodes. Women report physical blows directed to the head, breasts, abdomen, and genitalia. Sexual as­sault is common.

Battering and pregnancy in teenagers constitute a par­ticularly difficult situation. Adolescents may be more trapped in the abusive relationship because of their inex­perience. Many professionals and the adolescents them­selves ignore the violence because it may not be believ­able, because relationships are transient, and because the jealous and controlling behavior is interpreted as love and devotion. Routine screening for abuse and sexual assault is recommended for pregnant adolescents. Because preg­nancy in young adolescent girls is commonly the result of sexual abuse, the nurse should assess the desire to maintain the pregnancy (see Chapter 4 for further discussion).

Review of systems. During this portion of the inter­view, the woman is asked to identify and describe preex­isting or concurrent problems with any of the body sys­tems, and her mental status is assessed. The woman is questioned about physical symptoms she has experienced,

Prenatal Physical Examination

such as shortness of breath or pain. Pregnancy affects and is affected by all body systems; therefore information on the present status of the body systems is important in plan­ning care. For each sign or symptom described, the fol­lowing additional data should be obtained: body location, quality, quantity, chronology, setting, aggravating or alle­viating factors, and associated manifestations (onset, char­acter, course) (Seidel et al., 1999).

Physical examination. The initial physical examina­tion provides the baseline for assessing subsequent changes. The examiner should determine the patient's need for basic information regarding the structure of the genital organs and provide this information, along with a demonstration of the equipment that may be used and an explanation of the procedure itself. The interaction re­quires an unhurried, sensitive, and gentle approach with a matter-of-fact attitude.

The physical examination begins with assessment of vi­tal signs, including blood pressure, height, and weight. The bladder should be empty before pelvic examination.

Each examiner develops a routine for proceeding with the physical examination; most choose the head-to-toe pro­gression. Heart and breath sounds are evaluated, and ex­tremities are examined. Distribution, amount, and quality of body hair is of particular importance because the findings reflect nutritional status, endocrine function, and general emphasis on hygiene. The thyroid gland is assessed care­fully. The height of the fundus is noted if the first examina­tion is done after the first trimester of pregnancy. The typi­cal basic examination is usually completed without much discomfort for the healthy woman. During the examination the examiner needs to remain alert to the woman's clues that give direction to the remainder of the assessment and that indicate imminent untoward response such as supine hypotension. See Chapter 4 for a detailed description of the physical examination.

Whenever a pelvic examination is performed, the tone of the pelvic musculature and the need for the woman's knowledge of Kegel exercises (p. 74) are assessed. Particular attention is paid to the size of the uterus because this is an indication of the timing of gestation. The nurse present during the examination can coach the woman in breathing and relaxation techniques at this time, as needed. After this initial vaginal examination, other examinations are usually not done in follow-up visits unless medically indi­cated (Bergsjo & Villar, 1997).

Laboratory tests. The laboratory data yielded by the analysis of the specimens obtained during the examination provide important information concerning the symptoms of pregnancy and the woman's health status (Table 1).

Specimens are collected at the initial visit so that the cause of any abnormal findings can be treated. Testing for antibody to the human immunodeficiency virus (HIV) is strongly recommended for all pregnant women. The finding of risk factors during pregnancy may indicate the need to repeat some tests at other times. For example, exposure to tuberculosis or an STI would necessitate re­peat testing.

 

Table 1 Laboratory Tests in Prenatal Period
Laboratory test	Purpose
Hemoglobin/hematocrit/white blood cell count, differential	Detects anemia/detects infection
Hemoglobin electrophoresis	Identifies women with hemoglobinopathies (e.g., sickle cell anemia, thalassemia)
Blood type, Rh, and irregular antibody	Identifies those fetuses at risk for developing erythroblastosis fetalis or hyperbilirubinemia in neonatal period
Rubella titer	Determines immunity to rubella
Tuberculin skin testing; chest film after 20 weeks of gestation in women with reactive tuberculin tests	Screens for exposure to tuberculosis
Urinalysis, including microscopic examination of urinary sediment; pH, specific gravity, color, glucose, albumin, protein, RBC, white blood cell count, casts, acetone; hCG	Identifies women with unsuspected diabetes mellitus, renal disease, hypertensive disease of pregnancy; infection; pregnancy
Urine culture	Identifies women with asymptomatic bacteriuria
Renal function tests: BUN, creatinine, electrolytes, creatinine clearance, total protein excretion	Evaluates level of possible renal compromise in women with a history of diabetes, hypertension, or renal disease
Pap test	Screens for cervical intraepithelial neoplasia, herpes simplex type 2, and HPV
Vaginal or rectal smear for Neisseria gonorrhoeae, Chlamydia, HPV, GBS	Screens high risk population for asymptomatic infection GBS done at 35-37 weeks
RPR/VDRL/FTA-ABS	Identifies women with untreated syphilis
HIV* antibody, hepatitis B surface antigen, toxoplasmosis	Screens for infection
1-hour glucose tolerance	Screens for gestational diabetes; done at initial visit for women with risk factors; done at 24 to 28 weeks for all pregnant women
3-hour glucose tolerance	Screens for diabetes in women with elevated glucose level after 1-hour test; must have two elevated readings for diagnosis
Cardiac evaluation: ECG, chest x-ray film, and echo-cardiogram	Evaluates cardiac function in women with a history of hypertension or cardiac disease
BUN, Blood urea nitrogen; ECG, electrocardiogram; FTA-ABS, fluorescent treponemal antibody absorption test; GBS, group B streptococcus; hCG, human chorionic gonadotropin; HIV, human immunodeficiency virus; HPV, human papillomavirus; RPR, rapid plasma reagin.

 

Follow-up visits

Monthly visits are scheduled routinely during the first and second trimesters, although additional appointments may be made as the need arises. During the third trimester, starting with week 28, maternity visits are scheduled every 2 weeks until week 36, and then every week until birth. The pattern of interviewing the woman first and then as­sessing physical changes and performing laboratory tests is maintained.

Interview. Follow-up visits are less intensive than the initial prenatal visit. At each of these follow-up visits, the woman is asked to summarize relevant events that have occurred since the previous visit (Fig. 6). She is asked about her general emotional and physiologic well-being, complaints or problems, or questions she may have. Per­sonal and family needs are also identified and explored.

 

Fig. 6 Prenatal interview. (Courtesy Dee Lowdermilk, Chapel Hill, NC.)202

 

Emotional changes are common during pregnancy, and therefore it is reasonable for the nurse to ask whether the woman has experienced any mood swings, reactions to changes in her body image, bad dreams, or worries. Posi­tive feelings (her own and those of her family) are also noted. The reactions of family members to the pregnancy and the woman's emotional changes are recorded.

During the third trimester, current family situations and their effect on the woman are assessed, for example, sib­lings' and grandparents' responses to the pregnancy and the coming child. In addition, the following assessments of the woman and her family are made: warning signs of emergencies; signs of preterm and term labor; the labor process and concerns about labor; and fetal development and methods to assess fetal well-being. The nurse should ask if the woman is planning to attend childbirth prepara­tion classes and what she knows about pain management during labor.

A review of the woman's physical systems is appropri­ate at each prenatal visit, and any suspicious signs or symp­toms are assessed in depth. Discomforts reflecting adapta­tions to pregnancy are identified.

Physical examination. Reevaluation is a constant as­pect of a pregnant woman's care. At each visit, pulse and respirations are measured; blood pressure (same arm with woman sitting) is taken; her weight is determined, and whether the weight gain (or loss) is compatible with the overall plan for weight gain is evaluated; urine may be checked by dipstick; and the presence and degree of edema are noted. Abdominal inspection and palpation are done, as well as measurement of fundal height. While assessing the pregnant woman's abdomen with the woman in the lithotomy position during the second and third trimesters, the nurse must watch for the occurrence of supine hy­potension (see Emergency box). When a woman is lying in this position, the weight of abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure (BP) and a feeling of faintness.

 

 

EMERGE IM C Y Supine H y p o t e n s i o n SIGNS/SYMPTOMS Pallor Dizziness, faintness, breathlessness Tachycardia Nausea Clammy (damp, cool) skin; sweating INTERVENTIONS Position woman on her side until her signs/symptoms subside and vital signs stabilize within normal limits.

 

Careful interpretation of BP is important in the risk fac­tor analysis of all pregnant women. BP is evaluated on the basis of absolute values and the length of gestation and is interpreted in the light of modifying factors.

An absolute systolic BP of 140 mm Hg or more and a diastolic BP of 90 mm Hg or more suggests the presence of hypertension (Helewa et al., 1997). Although the BP of 140/90 mm Hg is an excellent point of reference, further investigation is needed. A rise in the systolic BP of 30 mm Hg more than the baseline pressure or in the diastolic BP of 15 mm Hg more than the baseline pressure is also a sig­nificant finding, regardless of the absolute values. An in­crease in BP could indicate the onset of pregnancy-induced hypertension (PIH) or preeclampsia (see Chapter 23).

The pregnant woman is monitored for signs and symp­toms that indicate other potential complications. For ex­ample, persistent and excessive vomiting and ketonuria may indicate the development of hyperemesis gravidarum. Uterine cramping and vaginal bleeding are signs of threat­ened miscarriage. Chills and fever are symptoms of infec­tion. Discharge from the vagina may be amniotic fluid or associated with infection (see Signs of Potential Complica­tions box).

 

Sign of potential complications
FIRST TRIMESTER
Signs/Symptoms	Possible Causes
Severe vomiting	Hyperemesis gravidarum
Chills, fever	Infection
Burning on urination	Infection
Diarrhea	Infection
Abdominal cramping; vaginal bleeding	Miscarriage, ectopic pregnancy
SECOND AND THIRD TRIMESTERS
Signs/Symptoms	Possible Causes
Persistent, severe vomiting	Hyperemesis gravidarum, hypertensive conditions, pregnancy-induced hypertension (PIH)
Sudden discharge of fluid from vagina before 37 weeks	Premature rupture of membranes (PROM)
Vaginal bleeding, severe abdominal pain	Miscarriage, placenta previa, abruptio placentae
Chills, fever, burning on urination, diarrhea	Infection
Severe backache or flank pain	Kidney infection or stones; preterm labor
Change in fetal movements: absence of fetal movements after quickening, any unusual change in pattern or amount	Fetal jeopardy or intrauterine fetal death
Uterine contractions; pressure; cramping before 37 weeks	Preterm labor
Visual disturbances: blurring, double vision, or spots	Hypertensive conditions, PIH
Swelling of face or fingers and over sacrum	Hypertensive conditions, PIH
Headaches: severe, frequent, or continuous	Hypertensive conditions, PIH
Muscular irritability or convulsions	Hypertensive conditions, PIH
Epigastric or abdominal pain (perceived as severe stomachache)	Hypertensive conditions, PIH, abruptio placentae
Glycosuria, positive glucose tolerance test reaction	Gestational diabetes mellitus
Sudden weight gain 2+ kg/wk	PIH

 

Fetal assessment. Toward the end of the first trimester, before the uterus is an abdominal organ, the fe­tal heart tones (FHTs) can be heard with an ultrasound fetoscope or an ultrasound stethoscope. To hear the FHTs the instrument is placed in the midline just anterior to the symphysis pubis and firm pressure applied. The woman and her family should be offered the opportunity to listen to the FHTs. The health status of the fetus is assessed at each visit for the remainder of the pregnancy.

Fundal height. During the second trimester the uterus becomes an abdominal organ. Measurement of the height of the uterus above the symphysis pubis is used as one in­dicator of fetal growth progress. During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman's bladder is empty at the time of measurement (Cunningham et al., 2001). The mea­surement also provides a gross estimate of the duration of pregnancy. In addition, it may aid in the identification of high risk factors. A stable or decreased fundal height may indicate the presence of intrauterine growth restriction; an excessive increase could indicate the presence of multifetal gestation or hydramnios.

A paper tape measure or a pelvimeter may be used to measure fundal height. To increase the reliability of the measurement, the same person could examine the pregnant woman at each of her prenatal visits, but often this is not possible because different clinicians may see the woman at prenatal visits. All clinicians who examine a particular preg­nant woman should be consistent in their measurement technique. Ideally, a protocol should be established for the health care setting in which the measurement technique is explicitly set forth and the woman's position on the exam­ining table, the measuring device, and the method of mea­surement used are specified. Fig. 7 illustrates two meth­ods for measuring fundal height.

 

Fig. 7 Measurement of fundal height from symphysis that (A) includes the upper curve of the fundus and (B) does not include the upper curve of the fundus. Note position of hands and measuring tape. (Courtesy Chris Rozales, San Francisco, CA.)

 

Gestational age. In an uncomplicated pregnancy, fe­tal gestational age is estimated after the duration of preg­nancy and the EDB are determined. Fetal gestational age is determined from the menstrual history, contraceptive history, pregnancy test result, and the following findings obtained during the clinical evaluation:

•  First uterine size estimate: date, size

•  Fetal heart first heard: date, Doppler stethoscope, fetoscope

•  Date of quickening (the pregnant woman's first percep­tion of fetal movement, usually occurring between the sixteenth and twentieth weeks of gestation)

•  Current fundal height, estimated fetal weight

•  Current week of gestation by history of LMP or ultra­ sound or both

•  Ultrasound: date, week of gestation, biparietal diameter

Routine use of ultrasound examination in early preg- nancy has been recommended (Crowley, 1998), and many health care providers have equipment readily available in the office. This procedure may be used to establish the du­ration of pregnancy if the woman cannot give a precise date for her LMP or if the size of the uterus does not cor­respond to the EDB calculated with Nagele's rule. Ultra­sound also provides information about the well-being of

the fetus; however, the routine use of ultrasound has not been found to substantively improve clinical outcomes (Neilson, 1998).

Health status. The assessment of fetal health status in­cludes consideration of fetal movement, the fetal heart rate (FHR) and rhythm, and abnormal maternal or fetal symptoms.

The woman is instructed to note the extent and timing of fetal movements and to report immediately if the pat­tern changes or if movement ceases. Regular movement has been found to be a reliable determinant of fetal health (Christensen & Rayburn, 1999). The FHR is checked on routine visits once it has been heard (Fig. 8). Early in the second trimester the heartbeat may be heard with the Doppler stethoscope (see Fig. 8, B). To detect the heart­beat before the fetus can be palpated by Leopold's ma­neuvers, the scope is moved around the ab­domen until the heartbeat is heard. Each nurse develops a set pattern for searching the abdomen for the heartbeat; for example, she may start first in the midline about 2 to 3 cm above the symphysis, then move to the left lower quadrant, and so on. The heart rate is counted and the quality and rhythm noted. Later in the second trimester the FHR can be determined with the fetoscope or Pinard stethoscope (see Fig. 8, A and Q. A normal rate and rhythm are other good indicators of fetal health. Once the heartbeat is noted, its absence is cause for immediate investigation.

 

 

Fig. 8 Detecting fetal heartbeat. A, Fetoscope (18 to 20 weeks). B, Doppler ultrasound stethoscope (12 weeks). C, Pinard's stethoscope. Note: Hands should not touch stethoscope while nurse is listening.

 

Fetal health status is intensively investigated if any ma­ternal or fetal complications arise (e.g., maternal hyperten­sion, intrauterine growth restriction [IUGR], premature rupture of membranes [PROM], irregular or absent FHR, absence of fetal movements after quickening). Careful, precise, and concise recording of patient responses and laboratory results contributes to the continuous supervi­sion vital to ensuring the well-being of the mother and fetus.

Laboratory tests. The number of routine laboratory tests done during pregnancy is limited. A clean-catch urine  specimen is obtained to test for glucose, protein, and ni­trites and leukocytes at each follow-up visit. Urine speci­mens for culture and sensitivity, as well as blood samples, are obtained only if signs and symptoms warrant. A he-matocrit determination is done at each visit in some of­fices. A blood specimen is obtained at 16 weeks to deter­mine the alpha-fetoprotein level.

The multiple-marker test, or triple-screen test, is used to detect Down syndrome. Done between 16 and 18 weeks of  gestation, it measures the maternal serum level of alpha-fetoprotein (MSAFP), human chorionic gonadotropin (hCG), and unconjugated estriol (Egan et al., 2000). Low levels of MSAFP may be associated with Down syndrome and other chromosomal abnormalities (see Chapter 21 for further discussion).

Some blood tests are repeated as necessary: for exam­ple, rapid plasma reagin/Venereal Disease Research Labo­ratory (RPR/VDRL) tests for syphilis; complete blood cell count with hematocrit, hemoglobin, and differential val­ues; antibody screen (Kell, Duffy, rubella, toxoplasmosis, anti-Rh, HIV; sickle cell; and level of folacin when indi- cated). If not done earlier in pregnancy, a glucose screen is performed in women over 25 years of age. A glucose chal­lenge is usually done between 24 and 28 weeks of gesta­tion. Cervical and vaginal smears are repeated as necessary to examine for Chlamydia organisms, gonorrhea, and her­pes simplex virus types 1 and 2. Group B streptococci (GBS) testing is done between 35 and 37 weeks of gesta­tion; cultures collected earlier will not accurately predict GBS status at time of birth.

Other tests. Other diagnostic tests are available to as­sess the health status of both the pregnant woman and the fetus. Ultrasonography, for example, may be performed to determine the status of the pregnancy and to confirm ges-tational age of the fetus. Amniocentesis, a procedure used to obtain amniotic fluid for analysis, may be needed to evaluate the fetus for genetic disorders or gestational ma­turity. These and other tests that are used to determine health risks for the mother and infant are described in Chapter 21.

After obtaining information through the assessment process, the data are analyzed to identify deviations from the norm and unique needs of this pregnant woman and her family. Although comprehensive health care requires collaboration among professionals from several disci­plines, nurses are in an excellent position to formulate di­agnoses that can be used to guide independent interven­tions. The following nursing diagnoses are examples that may be appropriate in the prenatal period:

•   Anxiety related to

- physical discomforts of pregnancy -ambivalent and labile emotions -changes in family dynamics -fetal well-being

•   Interrupted family processes related to -changing roles and responsibilities -inadequate understanding of physical and emo­tional changes in pregnancy

-increased concern about labor

• Imbalanced nutrition: less than body requirements related to

-inadequate understanding of nutritional requirements in pregnancy

-morning sickness

• Disturbed body image related to

-anatomic and physiologic changes of pregnancy

• Ineffective health maintenance related to deficient knowledge regarding self-care measures for

-posture and body mechanics

-rest and relaxation

-personal hygiene

-activity and exercise

-safety

• Ineffective individual coping related to deficient knowledge regarding

-recognizing onset of complications

-distinguishing between true and false labor

-emergency arrangements

• Disturbed sleep pattern related to

-discomforts of late pregnancy

 

Expected Outcomes of Care

The plan of nursing care for women and their families dur­ing pregnancy is given direction by the diagnoses that have been formulated during prenatal visits. Examples of out­comes that may be expected include that the pregnant woman will do the following:

•  Indicate decreased anxiety about the health of her fetus and herself

•  Describe improved family dynamics

•  Show appropriate weight gain patterns

•  Report acceptance of changes in body image

•  Demonstrate knowledge of self-care

•  Ask for clarification of information about pregnancy and birth

•  Report signs and symptoms of complications

•  Report measures that were effective in relieving physical discomforts

•  Develop a realistic birth plan