Nursing care during pregnancy

Nursing care during pregnancy. Childbirth and Perinatal education

Prepared by assistant professor N.Petrenko, MD, PhD

 

LEARNING OBJECTIVES

* 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.

 

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

 

Plan of Care and Interventions

The nurse-patient relationship is critical in setting the tone for further interaction. The clinic, home visits, or tele­phone conversations all provide opportunities for contact and can be used effectively for these interactions. Some­times women repeatedly seek information about a particu­lar problem. At other times, there may be another under­lying problem the woman is hesitant to discuss. The nurse needs to be astute in identifying such unvoiced needs and can help the woman by asking for a patient-generated so­lution and a subsequent report of its effectiveness.

 

Care Paths

Because a large number of health care professionals are in­volved in care of the expectant mother, unintentional gaps or overlaps in care may occur. Care paths are used to im­prove the consistency of care and reduce costs (Simon, Heaps, & Chodroff, 1997). Use of care paths may con­tribute to improved satisfaction of families with the pre­natal care that is provided, and members of the health care team may function more efficiently and effectively (see Care Path).

 

CARE PATH Prenatal Care Pathway

 

Education about maternal and fetal changes

Expectant parents are typically curious about the growth and development of the fetus and the consequent changes that occur in the mother's body. Women may be more tolerant of the discomforts related to the continuing pregnancy if they understand the underlying causes. Printed and audiovisual materials that describe fetal and maternal changes can be used in explaining changes as they occur. Table 7-1 summarizes fetal development.

Education for self-care

Health maintenance is an important aspect of prenatal care. Patient participation in care ensures prompt reporting of untoward responses to pregnancy. Patient assumption of responsibility of health maintenance is assisted by the nurse's understanding of maternal adaptations to the growth of the unborn child and a readiness to learn. Nurses in their role of teacher provide patients with the informa­tion necessary for adherence to health care guidelines.

The expectant woman needs information about many subjects. The nurse who is observant, listens, and knows typical concerns of expectant parents can anticipate ques­tions that will be asked and prompt mothers and fathers to discuss what is on their minds. Several topics that may cause concerns in pregnant women are discussed in the following sections.

Nutrition. Proper nutrition is an important factor in the maintenance of maternal health during pregnancy and the provision of adequate nutrients for embryonic and fe­tal development. Assessing a woman's nutritional status early in pregnancy and providing information on nutrition are part of the nurse's responsibilities in rendering prena­tal care. In some settings, a registered dietitian conducts classes for pregnant women on the topics of nutritional status and nutrition during pregnancy or interviews them to assess their knowledge of these topics. Nurses can refer women to a registered dietitian if a need is revealed during the nursing assessment. (For detailed information con­cerning maternal and fetal nutritional needs and related nursing care, see Chapter 10.)

Personal hygiene. During pregnancy, the sebaceous (sweat) glands are highly active because of hormonal in­fluences, and women often perspire freely. They may be re­assured that the increase is normal and that their previous patterns of perspiration will return after the postpartum period. Washing the body regularly is basic to good per­sonal hygiene. Baths and warm showers can be therapeu­tic because they relax tense, tired muscles, help counter insomnia, and make the pregnant woman feel fresh. Tub bathing is permitted even in late pregnancy because little water enters the vagina unless under pressure. However, late in pregnancy, when the woman's center of gravity low­ers, she is at risk for falling. Tub bathing is contraindicated after rupture of the membranes.

Prevention of urinary tract infections. Because of dramatic changes that occur in the renal system during pregnancy (see Chapter 8), urinary tract infections are common, but they may be asymptomatic. Women should know, however, to inform their health care provider if blood or pain occurs on urination or if other significant changes in the pattern of elimination occur. These infec­tions pose a risk to the mother and fetus, and thus the pre­vention and early treatment of these infections are essen­tial (Polivka, Nickel, & Wilkms, 1997).

The nurse can assess the woman's understanding and use of good handwashing techniques before and after urinating and whether she knows to wipe from front to back. Soft, absorbent toilet tissue, preferably white and un-scented, should be used, because harsh, scented, or printed toilet paper may cause irritation. Bubble bath or other bath oils should be avoided because these may be irritat­ing to the urethra. Women should wear underpants and panty hose with a cotton crotch and avoid wearing tight-fitting slacks or jeans for long periods, because anything that promotes a buildup of heat and moisture in the geni­tal area may foster the growth of bacteria.

Some women do not consume enough fluid and food. After discovering her food preferences, the nurse should advise the woman to drink 1.5 to 2 L (six to eight glasses) of liquid a day to maintain an adequate fluid intake that ensures frequent urination. Pregnant women should not limit fluids in an effort to reduce the frequency of urina­tion. Women need to know that if urine looks dark (con­centrated), they need to increase their fluid intake. Cran­berry juice may be suggested because it is more acidic than other fluids and makes the urinary tract less hospitable to bacteria by lowering the pH. The consumption of yogurt and acidophilus milk may also help prevent urinary tract and vaginal infections.

The nurse should review healthy urination practices with the woman. Women should be told not to ignore the urge to urinate because holding urine lengthens the time bacteria are in the bladder and thus allows them to multi­ply. Women should plan ahead when they are faced with situations that may require them to delay urination (e.g., a long car ride). They always should urinate before going to bed at night. Bacteria also can be introduced during inter­course. Therefore women are advised to urinate before and after intercourse, then drink a large glass of water to pro­mote additional urination.

Kegel exercises. Kegel exercises (exercises for the pelvic floor) strengthen the muscles around the reproduc­tive organs and improve muscle tone. Many women are not aware of the muscles of the pelvic floor until it is pointed out that these are the muscles used dur­ing urination and sexual intercourse and therefore can be consciously controlled. The muscles of the pelvic floor en­circle the outlet through which the baby must pass; it is im­portant that they be exercised, because an exercised muscle can then stretch and contract readily at the time of birth.

Practice of pelvic muscle exercises during pregnancy on a regular basis results in fewer complaints of urinary incon­tinence in late pregnancy and postpartum and can help prevent a prolapsed uterus and stress incontinence from oc­curring later in life (Sampselle et al, 1998). One method of performing Kegel exercises that is suggested is described in the Teaching Guidelines box, p. 74. The nurse can be rea­sonably assured that the teaching has been effective if the woman reports an increased ability to control urine flow and greater muscular control during sexual intercourse.

Preparation for breastfeeding the newborn. Preg­nant women are usually eager to discuss their plans for feed­ing the newborn. Breast milk is the food of choice, in part because breastfeeding is associated with a decreased inci­dence of perinatal morbidity and mortality. The American Academy of Pediatrics recommends breastfeeding for at least a year. However, a deep-seated aversion to breastfeed­ing on the part of the mother or partner; the mother's need for certain medications; and certain medical complications, such as active tuberculosis, newly diagnosed breast cancer, and hepatitis C, are contraindications to breastfeeding (Lawrence, 1999). Although hepatitis B antigen has not been shown to be transmitted via breast milk, as an added precaution it is recommended that infants born to hepatitis B antigen-positive women receive the hepatitis B vaccine and hepatitis B immune globulin immediately after birth. Women who are HIV positive are discouraged from nursing because of the risk of HIV transmission (Lawrence, 1999).

For women who want to breastfeed, the pinch test is done to determine whether the nipple is everted or in­verted (Fig. 9). The nurse shows the woman the way to perform the pinch test. It involves having the woman place her thumb and forefinger on her areola and gently press inward. This will cause her nipple to protrude or retract. Most nipples will protrude.

 

 

Fig. 9 A, Normal nipple everts with gentle pressure. B, Inverted nipple inverts with gentle pressure. (Modified from Lawrence, R. [1999]. Breastfeeding: A guide for the medical profession [5th ed.]. St. Louis: Mosby.)

 

Exercises to break the adhesions that cause the nipple to protrude do not work and may in fact precipitate uter­ine contractions (Lawrence, 1999). The use of breast shells by women with flat or inverted nipples may be recom­mended (Fig. 9-10). Breast shells work by exerting a con­tinuous, gentle pressure around the areola that pushes the nipple through a central opening in the inner shield. Breast shells should be worn for 1 to 2 hours daily during the last trimester of pregnancy. They should be worn for gradually increased lengths of time (Lawrence, 1999).

 

Fig. 10 Breast shell in place inside bra to evert nipple. (Modified from Lawrence, R. [1999]. Breastfeeding: A guide for the medical profession [5th ed.]. St. Louis: Mosby.)

 

The woman is taught to cleanse the nipples with warm water to keep the ducts from being blocked with dried colostrum. Soap, ointments, alcohol, and tinctures should not be applied because they remove protective oils that keep the nipples supple. The use of these substances may cause the nipples to crack during early lactation (Lawrence, 1999).

The woman who plans to breastfeed should purchase a nursing bra that will accommodate her increased breast size during the last few months of pregnancy and during lactation. If her breasts are very heavy, or if the woman feels uncomfortable with the weight unsupported, the bra can be worn day and night.

Dental care. Dental care during pregnancy is especially important because nausea during pregnancy may lead to poor oral hygiene, allowing dental caries to develop. No physiologic alteration during gestation can cause dental caries, however. Because calcium and phosphorus in the teeth are fixed in enamel, the old adage "for every child a tooth" is not true.

There is no scientific evidence that filling teeth or even dental extraction involving the administration of local or nitrous oxide-oxygen anesthesia precipitates miscarriage or premature labor. Antibacterial prophylaxis therapy should be considered for prevention of sepsis, however, es­pecially in pregnant women who have had rheumatic heart disease or nephritis.

Physical activity. Physical activity promotes a feeling of well-being in the pregnant woman. It improves circula­tion, promotes relaxation and rest, and counteracts bore­dom, as it does in the nonpregnant woman. Detailed exer­cise tips for pregnancy are presented in the Self-Care box. Exercises that help relieve the low back pain that often arises during the second trimester because of the increased weight of the fetus are demonstrated in Fig. 11. Exercise in pregnancy may also reduce the incidence of cesarean birth (see Research box).

 

 

Fig. 11 Exercises. A to C, Pelvic rocking relieves low backache (excellent for relief of men­strual cramps as well). D, Abdominal breathing aids relaxation and lifts abdominal wall off uterus.

 

RESEARCH Exercise Can Decrease Risk of Cesarean Exercise benefits to most healthy pregnant women include decreased physical discomforts, shortened labor, and possibly decreased cesarean births. Cesarean birth exposes women to the risk of infection; blood loss; bowel and respiratory complications; anesthesia reactions; and increased length of hospital stay, recovery, and expense. The stated goal of the U.S. Department of Health and Human Services is to decrease the cesarean rate to 15% of all births, but the rate has remained higher. To explore whether exercise in the first two trimesters affects the mode of birth, a retrospective study was conducted surveying 137 nulliparous pregnant women regarding their exercise habits. The women were classified as active if they exercised at least 20 minutes, three times a week, during their first two trimesters. The most popular exercises were vigorous walking and aerobics classes. Overall, the cesarean rate in this study was 24%; however, the rate for the active women was 15.9% and the rate for the sedentary women was 28%. There were no significant differences in the length of labor, birth weight, maternal weight gain, or length of gestation between the two groups. Although a causal association could not be proven in this study, the authors estimated that 12 per 100 cesarean births could be attributed to sedentary behavior. IMPLICATIONS FOR PRACTICE Physical activity is an attractive, cost-effective intervention that nurses should confidently recommend to all healthy pregnant women to reduce their risk of cesarean birth. Safety precautions should be discussed, including when exercise is contraindicated, what exercises to avoid, and how to recognize the problems of dehydration and overheating. Source: Bungum, I , Peaslee, D., Jackson, A., & Perez, M. (2000). Exercise during pregnancy and type of delivery in nulliparae. J Obstet Gynecol Neonatal Nurs, 29(3), 258-264.

 

Posture and body mechanics. Many maternal adapta­tions predispose the woman to having backache and incur­ring possible injury. The pregnant woman's center of grav­ity changes, pelvic joints soften and relax, and stress is placed on abdominal musculature as pregnancy progresses. Poor posture and body mechanics contribute to the dis­comfort and potential for injury. To minimize these prob­lems, women can acquire a kinesthetic sense for good body posture (Fig. 12). The activities described in the Self-Care box can also promote greater physical comfort.

 

Fig. 12 Correct body mechanics. A, Squatting. B, Lifting.

 

Patient Instructions for Self-Care Exercise Tips for Pregnant Women Consult your health care provider when you know or suspect you are pregnant. Discuss your medical and obstetric history, your current exercise regimen, and the exercises you would like to continue throughout pregnancy. Seek help in determining an exercise routine that is well within your limit of tolerance, especially if you have not been exercising regularly. Consider decreasing weight-bearing exercises (jogging, running) and concentrating on non-weight-bearing ac­tivities such as swimming, cycling, or stretching. If you are a runner, starting in your seventh month, you may wish to walk instead. Avoid risky activities such as surfing, mountain climbing, skydiving, and racquetball because such activities that require precise balance and coordination may be dan­gerous. Avoid activities that require holding your breath and bearing down (Valsalva maneuver). Jerky, bouncy motions also should be avoided. Exercise regularly at least three times a week, as long as you are healthy, to improve muscle tone and increase or maintain your stamina. If you do exercises sporadically, this may put undue strain on your muscles. Limit activ­ity to shorter intervals. Exercise for 10 to 15 minutes, rest for 2 to 3 minutes, then exercise for another 10 to 15 minutes. Decrease your exercise level as your pregnancy pro­gresses. The normal alterations of advancing preg­nancy, such as decreased cardiac reserve and increased respiratory effort, may produce physiologic stress if you exercise strenuously for a long time. Take your pulse every 10 to 15 minutes while you are ex­ercising. If it is more than 140 beats/min, slow down un­til it returns to a maximum of 90 beats/min. You should be able to converse easily while exercising. If you can­not, you need to slow down. Avoid becoming overheated for extended periods of time. It is best not to exercise for more than 35 min­utes, especially in hot, humid weather. As your body temperature rises, the heat is transmitted to your fetus. Prolonged or repeated elevation of fetal tem­perature may result in birth defects, especially during the first 3 months. Your temperature should not ex­ceed 38° C. Avoid the use of hot tubs and saunas. Warm-up and stretching exercises prepare your joints for more strenuous exercise and lessen the likelihood of strain or injury to your joints. After the fourth month of gestation you should not perform exercises flat on your back. A cool-down period of mild activity involving your legs af­ter an exercise period will help bring your respiration, heart, and metabolic rates back to normal and prevent the pooling of blood in the exercised muscles. Rest for 10 minutes after exercising, lying on your side. As the uterus grows, it puts pressure on a major vein in your abdomen, which carries blood to your heart. Lying on your side removes the pressure and promotes return circulation from your extremities and muscles to your heart, thereby increasing blood flow to your placenta and fetus. You should rise gradually from the floor to prevent dizziness or fainting (orthostatic hypotension). Drink two or three 8-ounce glasses of water after you ex­ercise to replace the body fluids lost through perspira­tion. While exercising, drink water whenever you feel the need. Increase your caloric intake to replace the calories burned during exercise and provide the extra energy needs of pregnancy. (Pregnancy alone requires an additional 300 kcal/day.) Choose such high-protein foods as fish, milk, cheese, eggs, or meat. Take your time. This is not the time to be competitive or train for activities requiring long endurance. Wear a supportive bra. Your increased breast weight may cause changes in posture and put pressure on the ulnar nerve. Wear supportive shoes. As your uterus grows, your cen­ter of gravity shifts and you compensate for this by arching your back. These natural changes may make you feel off balance and more likely to fall. Stop exercising immediately if you experience shortness of breath, dizziness, numbness, tingling, pain of any kind, more than four uterine contractions per hour, de­creased fetal activity, or vaginal bleeding, and consult your health care provider.   Posture and Body Mechanics TO PREVENT OR RELIEVE BACKACHE Do pelvic tilt; •  Pelvic tilt (rock) on hands and knees (see Fig. 9-11, A) and while sitting in straight-back chair. •  Pelvic tilt (rock) in standing position against a wall, or lying on floor (see Fig. 11, Sand C). •  Perform abdominal muscle contractions during pelvic tilt while standing, lying, or sitting to help strengthen rectus abdominis muscle (see Fig. 11, D). •  Use good body mechanics. •  Use leg muscles to reach objects on or near floor. Bend at the knees, not the back. Knees are bent to lower body to squatting position. Feet are kept 12 to 18 inches apart to provide a solid base to maintain balance (see Fig. 12, A). •  Lift with the legs. To lift heavy object (young child), one foot is placed slightly in front of the other and kept flat as you lower yourself onto one  knee. Lift the weight holding it close to your body and never higher than the chest. To stand up or sit down, one leg is placed slightly behind the other as you raise or lower yourself (see Fig. 12, B). TO RESTRICT THE LUMBAR CURVE For prolonged standing (e.g., ironing, out-of-home em­ployment), place one foot on low footstool or box; change positions often. Move car seat forward so that knees are bent and higher than hips. If needed, use a small pillow to sup­port low back area. Sit in chairs low enough to allow both feet to be placed on floor and preferably with knees higher than hips. TO PREVENT ROUND LIGAMENT PAIN AND STRAIN ON ABDOMINAL MUSCLES Implement suggestions given inTable 2   Modified from American College of Obstetricians and Gynecologists. (1994b). Exercise during pregnancy and the postpartum period. Technical Bulletin No. 189. Washington, DC: ACOG; Artal, R., & Subak-Sharpe, G. (1998). Pregnancy and exercise. New York: Delacorte Press; Fishbein, E., & Phillips, M. (1990). How safe is exercise during pregnancy? J Obstet Gynecol Neonatal Nurs, 79(1), 45-49; Kramer, M. (2001). Regular aerobic exercise during pregnancy (Cochrane Review). In the Cochrane Library, 1, Oxford: Update Software; and Pivarnik, J. (1994). Maternal exercise in pregnancy. Sports Med, 73,215-217.

 

Rest and relaxation. The pregnant woman is encour­aged to plan regular rest periods, particularly as pregnancy advances. The side-lying position (Fig. 13) is recom­mended because it promotes uterine perfusion and feto-placental oxygenation by eliminating pressure on the as­cending vena cava and descending aorta, which can lead to supine hypotension. The woman should also be shown the way to rise slowly from a side-lying position to prevent placing strain on the back and to minimize the orthostatic hypotension caused by changes in position common in the latter part of pregnancy. To stretch and rest back mus­cles at home or work, the nurse can show the woman how to do the following exercises:

* Stand behind a chair. Support and balance self using the back of the chair (Fig. 14). Squat for 30 seconds; stand for 15 seconds. Repeat six times, several times per day, as needed.

* While sitting in a chair, lower head to knees for 30 sec­onds. Raise head up. Repeat six times, several times per day, as needed.

Conscious relaxation is the process of releasing tension from the mind and body through conscious effort and practice. The ability to relax consciously and intentionally can be beneficial for the following reasons:

* Normal discomforts related to pregnancy can be relieved.

* Stress can be reduced, thus diminishing pain perception during the childbearing cycle.

* Self-awareness and trust in one's own ability to control one's responses and function can be heightened.

* The woman can better cope with stress in everyday life situations, whether she is pregnant or not.

The techniques for conscious relaxation are numerous and varied. The guidelines given in Box 2 can be used by anyone.

Fig. 13 Side-lying position for rest and relaxation. Some women prefer to support upper part of leg with pillows

 

Fig. 14 Squatting for muscle relaxation and strength­ening and for keeping leg and hip joints flexible.

 

BOX 2 Conscious Relaxation Tips Preparation: Loosen clothing, assume a comfortable sitting or side-lying position with all parts of body well supported with pillows. Beginning: Allow self to feel warm and comfortable. Inhale and exhale slowly, and imagine peaceful re­laxation coming over each part of the body, starting with the neck and working down to the toes. Often people who learn conscious relaxation speak of feeling relaxed even if some discomfort is present. Maintenance: Use imagery (fantasy or daydream) to maintain the state of relaxation. Using active im­agery, imagine yourself moving or doing some activ­ity and experiencing its sensations. Using passive im­agery, imagine yourself watching a scene, such as a lovely sunset. Awakening: Return to the wakeful state gradually. Slowly begin to take in stimuli from the surrounding environment. Further retention and development of the skill: Practice regularly for some periods each day, for example, at the same hour for 10 to 15 minutes each day, to feel refreshed, revitalized, and invigorated.

 

Employment. Employment of pregnant women usu­ally has no adverse effects on pregnancy outcomes. Job dis­crimination that is based strictly on pregnancy is illegal. However, some job environments (e.g., dry cleaning plants, chemistry laboratories, operating rooms, parking garages) pose potential risk to the fetus.

Activities that depend on a good sense of balance should be discouraged, however, especially during the lat­ter half of pregnancy. Commonly, excessive fatigue is the deciding factor in the termination of employment. Women in sedentary jobs need to walk around at intervals to counter the usual sluggish circulation in the legs that can cause varices and thrombophlebitis to develop. They should neither sit nor stand in one position for long peri­ods and should avoid crossing their legs at the knees be­cause these foster such conditions. The pregnant woman's chair should provide adequate back support. Use of a foot­stool can prevent pressure on veins, relieve strain on vari-cosities, and minimize swelling of feet. Standing for long periods of time also increases the risk of preterm labor.

Clothing. Comfortable, loose clothing is best. Wash­able fabrics (e.g., absorbent cottons) are often preferred. Maternity clothes may be purchased new or found at thrift shops or garage sales in good condition because they rarely wear out. Tight bras and belts, stretch pants, garters, tight-top knee socks, panty girdles, and other constrictive cloth­ing should be avoided because tight clothing over the per­ineum encourages vaginitis and miliaria (heat rash), and impaired circulation in the legs can cause varicosities.

Maternity bras are constructed to accommodate the in­creased breast weight, chest circumference, and size of breast tail tissue (under the arm). These bras also have drop-flaps over the nipples to facilitate breastfeeding. A good bra can help prevent neckache and backache.

Elastic hose give considerable comfort and promote greater venous emptying in women with large varicose veins. Ideally, support stockings should be put on before the woman gets out of bed in the morning. Fig. 9-15 demon­strates a position to rest the legs and reduce swelling. If this position is used, a pillow should be placed under one hip to prevent supine hypotension.

 

Fig. 15 Position for resting legs and for reducing edema and varicosities. Encourage woman with vulvar varicosities to include pillow under her hips. (Courtesy Dale Ikuta, San Jose, CA.)

 

Comfortable shoes that provide firm support and pro­mote good posture and balance are also advisable. Very high heels and platform shoes are not recommended because of the woman's changed center of gravity, which can cause her to lose her balance and cause leg aches and cramps (Fig. 16). In addition, in the third trimester the woman's pelvis tilts for­ward and her lumbar curve increases.

 

Fig. 16 Relief of muscle spasm (leg cramps). A, An­other person dorsiflexes foot with knee extended. B, Woman stands and leans forward, thereby dorsiflexing foot of affected leg.

 

Travel. Travel is not contraindicated in low risk preg­nant women, but those with high risk pregnancies are ad­vised to avoid long-distance travel after fetal viability has been reached so as to avert the economic and psychologic consequences of giving birth to a preterm infant far from home. Travel to areas where medical care is poor, water is untreated, or malaria is prevalent should be avoided if pos­sible. Women who contemplate international travel should be aware that many health insurance carriers do not cover a birth or even hospitalization for preterm labor outside of the country where the policy is activated.

Pregnant women who travel for long distances should schedule periods of activity and rest. While sitting the woman can practice deep breathing, foot circling, and al­ternately contracting and relaxing different muscle groups. She should avoid becoming fatigued. Although travel in it­self is not a cause of adverse outcomes such as miscarriage or preterm labor, maternal death resulting from injury sus­tained in an accident is the most common cause of fetal death. The next most common cause is placental separa­tion. This occurs because body contours change in reac­tion to the force of a collision. The uterus as a muscular organ can adapt its shape to that of the body, but the pla­centa is not resilient; therefore, at the impact of collision, placental separation can occur.

Certain precautions are recommended while traveling in a car. A combination lap belt and shoulder harness is the most effective automobile restraint (Fig. 17), and both should be used. The lap belt should be worn low across the pelvic bones and as snug as is comfortable. The shoulder harness should be worn above the pregnant uterus and below the neck to prevent chafing. The preg­nant woman should sit upright. The headrest should be used to avoid a whiplash injury.

 

Fig. 17 Proper use of seat belt and headrest. (Courtesy Tammie McGee, Millbrae, CA.)

 

 

Airline travel in large commercial jets usually poses lit­tle risk to the pregnant woman. Policies vary from airline to airline, so the pregnant woman is advised to inquire about restrictions or recommendations from the airline (Cunningham et al., 2001). Magnetometers (metal detec­tors) used at airport security checkpoints are not harmful to the fetus. The 8% humidity at which the cabins of com­mercial airlines are maintained may result in some water loss; hydration (with water) should therefore be main­tained under these conditions. Sitting in the cramped seat of an airliner for prolonged periods may increase the risk of superficial and deep thrombophlebitis. A pregnant woman is encouraged to take a 15-minute walk around the aircraft during each hour of travel to minimize this risk; support stockings may also be worn. A seat in the non­smoking section of flights on which smoking is permitted is advised to prevent her carboxyhemoglobin levels from becoming elevated (see Teaching Guidelines box).

 

TEACHING GUIDELINES Safety During Pregnancy Maternal adaptations to pregnancy involve relaxation of joints, alteration to center of gravity, faintness, and discomforts. Problems with coordination and balance are common. Therefore the woman should follow these guidelines: * Use good body mechanics. * Use safety features on tools/vehicles (safety seatbelts, shoulder harnesses, headrests, goggles, hel­mets) as specified. * Avoid activities requiring coordination, balance, and concentration. * Take rest periods; reschedule daily activities to meet rest and relaxation needs. Embryonic and fetal development is vulnerable to envi­ronmental teratogens. Many potentially dangerous chemicals are present in the home, yard, and work­place: cleaning agents, paints, sprays, herbicides, and pesticides. The soil and water supply may be unsafe. Therefore the woman should follow these guidelines: * Read all labels for ingredients and proper use of product. * Ensure adequate ventilation with clean air. * Dispose of wastes appropriately. * Wear gloves when handling chemicals. * Change job assignments or workplace as necessary. * Avoid high altitudes (except in pressurized aircraft), which could jeopardize oxygen intake

 

Medications. Although much has been learned about fetal drug toxicity, the possible teratogenicity of many medications, prescription and OTC, is still unknown. This is especially true for new medications, combinations of drugs, and herbal therapies. Moreover, certain subclinical errors or deficiencies in intermediate metabolism in the fe­tus may cause an otherwise harmless drug to be converted into a hazardous one. The greatest danger of drug-caused developmental defects in the fetus extends from the time of fertilization through the first trimester, a time when the woman may not realize she is pregnant. Self-treatment is discouraged. Information about the use of OTC medica­tions, vitamins, and herbal preparations should be shared by the pregnant woman with her health care providers.

Immunizations. There has been some concern over the safety of various immunization techniques during pregnancy (Cunningham et al., 2001). Immunization with live or attenuated live viruses is contraindicated during pregnancy because of its potential teratogenicity. Live-virus vaccines include those for measles (rubeola and rubella), chickenpox, and mumps. Vaccines consisting of killed viruses may be used. Those that may be adminis­tered during pregnancy include tetanus, diphtheria, re-combinant hepatitis A and B, influenza (after the first trimester), and rabies vaccines (American College of Ob­stetricians and Gynecologists [ACOG], 1999).

Alcohol, cigarette smoke, and other substances. A safe level of alcohol consumption during pregnancy has not been established. Although the consumption of occa­sional alcoholic beverages may not be harmful to the mother or her developing embryo or fetus, complete ab­stinence is strongly advised (ACOG, 1994a). Maternal al­coholism is associated with high rates of miscarriage and fetal alcohol syndrome; the risk for miscarriage in the first trimester is dose related (three or more drinks per day). Growing evidence indicates that the pattern of drinking (frequency, timing, and duration), especially in the first trimester, is more predictive of fetal damage than the amount (Abel, 1996; Wagner et al, 1998).

Cigarette smoking or continued exposure to a smoke-filled environment (even if the mother does not smoke) is associated with fetal growth restriction and an increase in perinatal and infant morbidity and mortality rates (Ward, 1999). Smoking is associated with an increased frequency of preterm labor, PROM, abruptio placentae, placenta pre-via, and fetal death resulting possibly from decreased pla-cental perfusion.

All pregnant women who smoke should be strongly en­couraged to quit or at least cut down. Pregnant women need to be told about the negative effects of even second­hand smoke on the fetus (ACOG, 1997).

Most studies of human pregnancy have revealed no as­sociation between caffeine consumption and birth defects or low birth weight (LBW). Because other effects are un­known, however, pregnant women are advised to limit their caffeine intake to 300 mg or less per day (Hally, 1998).

Any drug or environmental agent that enters the preg­nant woman's bloodstream has the potential to cross the placenta and harm the fetus. Marijuana, heroin, and co­caine are common examples of such substances (see Chap­ter 27 for neonatal effects).

Normal discomforts. Pregnant women are confronted with symptoms that would be considered abnormal in the nonpregnant state. Much of the prenatal care requested by women pregnant for the first time is prompted by the need for explanations of the causes of the discomforts and for advice on ways to relieve the discomforts. The discomforts of the first trimester are fairly specific. Information about the physiology and prevention of and self-care for discom­forts experienced during the three trimesters is given in Table 2. Box 3 lists alternative and complementary ther-apies and why they might be used in pregnancy (Fig. 18). Nurses can do much to allay a first-time mother's anxiety about such symptoms by telling her about them in ad­vance, using terminology that the woman (or couple) can understand. Women who understand the physical discom­forts of pregnancy are less apt to become overly anxious about their health. In addition, understanding the rationale for treatment promotes their participation in their care.

 

Table 2 Discomfort related to Pregnancy
DISCOMFORT	PHYSIOLOGY	EDUCATION
FIRST TRIMESTER
Breast changes, new sensation: pain, tingling, tenderness	Hypertrophy of mammary glandular tissue and increased vascularization, pigmentation, and size and prominence of nipples and areolae caused by hormonal stimulation	Wear supportive maternity bras with pads to absorb discharge, may be worn at night; wash with warm water and keep dry; breast tenderness may interfere with sexual expression/foreplay but is temporary
Urgency and frequency of urination	Vascular engorgement and altered bladder function caused by hormones; bladder capacity reduced by enlarging uterus and fetal presenting part	Empty bladder regularly; perform Kegel exercises; limit fluid intake before bedtime; wear perineal pad; report pain or burning sensation to primary health care provider
Languor and malaise; fatigue (early pregnancy, usually)	Unexplained; may be caused by increasing levels of estrogen, progesterone, and hCG or by elevated BBT; psychologic response to pregnancy and its required physical/psychologic adaptations	Rest as needed; eat well-balanced diet to prevent anemia
Nausea and vomiting, morning sickness—occurs in 50% to 75% of pregnant women; starts between first and second missed periods and lasts until about fourth missed period; may occur any time during day; fathers also may have symptoms	Cause unknown; may result from hormonal changes, possibly hCG; may be partly emotional, reflecting pride in, ambivalence about, or rejection of pregnant state	Avoid empty or overloaded stomach; maintain good posture—give stomach ample room; stop smoking; eat dry carbohydrate on awakening; remain in bed until feeling subsides, or alternate dry carbohydrate 1 hour with fluids such as hot herbal decaffeinated tea, milk, or clear coffee the next hour until feeling subsides; eat five to six small meals per day; avoid fried, odorous, spicy, greasy, or gas-forming foods; consult primary health care provider if intractable vomiting occurs; acupressure (see Fig. 18)
Ptyalism (excessive salivation) may occur starting 2 to 3 weeks after first missed period	Possibly caused by elevated estrogen levels; may be related to reluctance to swallow because of nausea	Use astringent mouth wash; chew gum
Gingivitis and epulis (hyperemia, hypertrophy, bleeding, tenderness); condition will disappear spontaneously 1 to 2 months after birth	Increased vascularity and proliferation of connective tissue from estrogen stimulation	Eat well-balanced diet with adequate protein and fresh fruits and vegetables; brush teeth gently and observe good dental hygiene; avoid infection; see dentist
Nasal stuffiness; epistaxis (nosebleed)	Hyperemia of mucous membranes related to high estrogen levels	Use humidifier; avoid trauma; normal saline nose drops or spray may be used
Leukorrhea: often noted throughout pregnancy	Hormonally stimulated cervix becomes hypertrophic and hyperactive, producing abundant amount of mucus	Not preventable; do not douche; wear perineal pads; perform hygienic practices such as wiping front to back; report to primary health care provider if accompanied by pruritus, foul odor, or change in character or color
Psychosocial dynamics, mood swings, mixed feelings	Hormonal and metabolic adaptations; feelings about female role, sexuality, timing of pregnancy, and resultant changes in life and lifestyle	Participate in pregnancy support group; communicate concerns to partner, family, and others; request referral for supportive services if needed (financial assistance)
SECOND TRIMESTER
Pigmentation deepens, acne, oily skin	Melanocyte-stimulating hormone (from anterior pituitary)	Not preventable; usually resolves during puerperium; keep skin clean
Spider nevi (angiomas) appear over neck, thorax, face, and arms during second or third trimesters	Focal networks of dilated arterioles (endarteries) from increased concentration of estrogens	Not preventable; they fade slowly during late puerperium; rarely disappear completely
Palmar erythema occurs in 50% of pregnant women; may accompany spider nevi	Diffuse reddish mottling over palms and suffused skin over thenar eminencies and fingertips may be caused by genetic predisposition or hyperestrogenism	Not preventable; condition will fade within 1 week after giving birth
Pruritus (noninflammatory)	Unknown cause; various types as follows: nonpapular; closely aggregated pruritic papules Increased excretory function of skin and stretching of skin possible factors	Keep fingernails short and clean; contact primary health care provider for diagnosis of cause Not preventable; symptomatic: Keri baths; mild sedation Distraction; tepid baths with sodium bicarbonate or oatmeal added to water; lotions and oils; change of soaps or reduction in use of soap; loose clothing
Palpitations	Unknown; should not be accompanied by persistent cardiac irregularity	Not preventable; contact primary health care provider if accompanied by symptoms of cardiac decompensation
Supine hypotension (vena cava syndrome) and bradycardia	Induced by pressure of gravid uterus on ascending vena cava when woman is supine; reduces uterine-placental and renal perfusion	Side-lying position or semisitting posture, with knees slightly flexed
Faintness and, rarely, syncope (orthostatic hypotension) may persist throughout pregnancy	Vasomotor lability or postural hypotension from hormones; in late pregnancy may be caused by venous stasis in lower extremities	Moderate exercise, deep breathing, vigorous leg movement; avoid sudden changes in position* and warm crowded areas; move slowly and deliberately; keep environment cool; avoid hypoglycemia by eating 5 to 6 small meals per day; wear elastic hose; sit as necessary; if symptoms are serious, contact primary health care provider
Food cravings	Cause unknown; craving determined by culture or geographic area	Not preventable; satisfy craving unless it interferes with well-balanced diet; report unusual cravings to primary health care provider
Heartburn (pyrosis or acid indigestion): burning sensation, occasionally with burping and regurgitation of a little sour-tasting fluid	Progesterone slows Gl tract motility and digestion, reverses peristalsis, relaxes cardiac sphincter, and delays emptying time of stomach; stomach displaced upward and compressed by enlarging uterus	Limit or avoid gas-producing or fatty foods and large meals; maintain good posture; sip milk for temporary relief; hot herbal tea, chewing gum; primary health care provider may prescribe antacid between meals; contact primary health care provider for persistent symptoms
Constipation	Gl tract motility slowed because of progesterone, resulting in increased resorption of water and drying of stool; intestines compressed by enlarging uterus; predisposition to constipation because of oral iron supplementation	Drink six glasses of water per day; include roughage in diet; moderate exercise; maintain regular schedule for bowel movements; use relaxation techniques and deep breathing; do not take stool softener, laxatives, mineral oil, other drugs, or enemas without first consulting primary health care provider
Flatulence with bloating and belching	Reduced Gl motility because of hormones, allowing time for bacterial action that produces gas; swallowing air	Chew foods slowly and thoroughly; avoid gas-producing foods, fatty foods, large meals; exercise; maintain regular bowel habits
Varicose veins (varicosities): may be associated with aching legs and tenderness; may be present in legs and vulva; hemorrhoids are varicosities in perianal area	Hereditary predisposition; relaxation of smooth muscle walls of veins because of hormones causing tortuous dilated veins in legs and pelvic vasocongestion; condition aggravated by enlarging uterus. gravity, and bearing down for bowel movements; thrombi from leg varices rare but may be produced by hemorrhoids	Avoid obesity, lengthy standing or sitting, constrictive clothing, and constipation and bearing down with bowel movements; moderate exercises; rest with legs and hips elevated (see Fig. 15); wear support stockings; thrombosed hemorrhoid may be evacuated; relieve swelling and pain with warm sitz baths, local application of astringent compresses
Leukorrhea: often noted throughout pregnancy	Hormonally stimulated cervix becomes hypertrophic and hyperactive, producing abundant amount of mucus	Not preventable; do not douche; maintain good hygiene; wear perineal pads; report to primary health care provider if accompanied by pruritus, foul odor, or change in character or color
Headaches (through week 26)	Emotional tension (more common than vascular migraine headache); eye strain (refractory errors); vascular engorgement and congestion of sinuses resulting from hormone stimulation	Conscious relaxation; contact primary health care provider for constant "splitting" headache, to assess for pregnancy-induced hypertension (PIH)
Carpal tunnel syndrome (involves thumb, second, and third fingers, lateral side of little finger)	Compression of median nerve resulting from changes surrounding tissues; pain, numbness, tingling, burning; loss of skilled movements (typing); dropping of objects	Not preventable; elevate affected arms; splinting of affected hand may help; regressive after pregnancy; surgery is curative
Periodic numbness, tingling of fingers (acrodysesthesia) occurs in 5% of pregnant women	Brachial plexus traction syndrome resulting from drooping of shoulders during pregnancy (occurs especially at night and early morning)	Maintain good posture; wear supportive maternity bra; condition will disappear if lifting and carrying baby does not aggravate it
Round ligament pain (tenderness)	Stretching of ligament caused by enlarging uterus	Not preventable; rest, maintain good body mechanics to avoid overstretching ligament; relieve cramping by squatting or bringing knees to chest, sometimes heat helps
Joint pain, backache, and pelvic pressure; hypermobility of joint	Relaxation of symphyseal and sacroiliac joints because of hormones, resulting in unstable pelvis; exaggerated lumbar and cervicothoracic curves caused by change in center of gravity resulting from enlarging abdomen	Maintain good posture and body mechanics; avoid fatigue; wear lowheeled shoes; abdominal supports may be useful; conscious relaxation; sleep on firm mattress; apply local heat or ice; get back rubs; do pelvic rock exercise; rest; condition will disappear 6 to 8 weeks after birth
THIRD TRIMESTER
Shortness of breath and dyspnea occur in 60% of pregnant women	Expansion of diaphragm limited by enlarging uterus; diaphragm is elevated about 4 cm; some relief after lightening	Good posture; sleep with extra pillows; avoid overloading stomach; stop smoking; contact health care provider if symptoms worsen to rule out anemia, emphysema, and asthma
Insomnia (later weeks of pregnancy)	Fetal movements, muscle cramping, urinary frequency, shortness of breath, or other discomforts	Reassurance; conscious relaxation; back massage or effleurage; support of body parts with pillows; warm milk or warm shower before retiring
Psychosocial responses: mood swings, mixed feelings, increased anxiety	Hormonal and metabolic adaptations; feelings about impending labor, birth, and parenthood	Reassurance and support from significant other and nurse; improved communication with partner, family, and others
Gingivitis and epulis (hyperemia, Increased vascularity and proliferation hypertrophy, bleeding, tenderness): of connective tissue from estrogen condition will disappear spontaneously stimulation 1 to 2 months after birth	Increased vascularity and proliferation of connective tissue from estrogen stimulation	Well-balanced diet with adequate protein and fresh fruits and vegetables; gentle brushing and good dental hygiene; avoid infection; see dentist for teeth cleaning
Urinary frequency and urgency return	Vascular engorgement and altered bladder function caused by hormones; bladder capacity reduced by enlarging uterus and fetal presenting part	Empty bladder regularly, Kegel exercises; limit fluid intake before bedtime; reassurance; wear perineal pad; contact health care provider for pain or burning sensation
Perineal discomfort and pressure	Pressure from enlarging uterus, especially when standing or walking; multifetal gestation	Rest, conscious relaxation, and good posture; contact health care provider for assessment and treatment if pain is present
Braxton Hicks contractions	Intensification of uterine contractions in preparation for work of labor	Reassurance; rest; change of position; practice breathing techniques when contractions are bothersome; effleurage; if contractions, do not go away with interventions, call your health care provider
Leg cramps (gastrocnemius spasm), especially when reclining	Compression of nerves supplying lower extremities because of enlarging uterus; reduced level of diffusible serum calcium or elevation of serum phosphorus; aggravating factors: fatigue, poor peripheral circulation, pointing toes when stretching legs or when walking, drinking more than 1 L (2 qt) of milk per day	Check for Homans' sign; if negative, use massage and heat over affected muscle; dorsiflex foot until spasm relaxes (Fig. 16); stand on cold surface; oral supplementation with calcium carbonate tablets; aluminum hydroxide gel, 30 ml, with each meal removes phosphorus by absorbing it
Lower-leg and ankle edema (nonpitting)	Edema aggravated by prolonged standing, sitting, poor posture, lack of exercise, constrictive clothing (e.g., garters), or by hot weather	Ample fluid intake for natural diuretic effect; put on support stockings before arising; rest periodically with legs and hips elevated (see Fig. 15), exercise moderately; contact health care provider if generalized edema develops; diuretics are contraindicated

 

 

 

BOX 3 Complementary and Alternative Therapies Used in Pregnancy MORNING SICKNESS AND HYPEREMESIS Acupuncture Acupressure (see Fig. 18) Shiatzu Herbal remedies* Peppermint Spearmint Ginger root Raspberry leaf Fennel Chamomile Hops Meadowsweet Wild yam root RELAXATION AND MUSCLE ACHE RELIEF Yoga Biofeedback Reflexology Therapeutic touch From Beal, M. (1998). Women's use of complementary and alternative therapies in re­productive health. J Nurse Midwifery, 43(3), 224-233; and Schirmer, G. (1998). Herbal medicine. Bedford, TX: MED2000 Inc. *Some herbs can cause miscarriage, preterm labor, or fetal or maternal injury. Preg­nant women should discuss use with pregnancy health care provider, as well as an ex­pert qualified in the use of the herb.

 

NURSE ALERT Although complementary and alternative therapies may benefit the woman during preg­nancy, some practices should be avoided because they may cause miscarriage or preterm labor (Beal, 1998). It is important to ask the woman what therapies she may be using.

 

Fig. 18 A, Pericardium 6 (p6) acupressure point for nausea. B, Sea Bands used for stimulation of acupressure point p6. (B, Courtesy Sea Band International, Newport, Rl.)

 

Recognizing potential complications. One of the most important responsibilities of persons involved in the care of the pregnant woman is to alert her to signs and symptoms that indicate a potential complication of preg­nancy. The woman needs to know how to report such warn­ing signs (see Signs of Potential Complications box, p. 202). When one is stressed by a disturbing symptom, it is difficult to remember specifics. Therefore the pregnant woman and her family are reassured if they receive a printed form listing the signs and symptoms that warrant an investigation and the phone numbers to call in an emergency.

The nurse needs to answer questions honestly as they arise during pregnancy. It is often difficult for the pregnant woman to know when to report signs and symptoms. The woman is encouraged to refer to the printed list of poten­tial complications and to listen to her body. If she senses that something is wrong, she should call her care provider.

 

NURSE ALERT Signs and symptoms that the woman needs to report immediately to her health care provider include vaginal bleeding, alteration in fetal movements, symptoms of PIH, rupture of mem­branes, and preterm labor.

 

Recognizing preterm labor. Teaching each mother-to-be to recognize preterm labor is necessary. Preterm labor is that which occurs after the twentieth week but before the thirty seventh week of pregnancy. It is a condition in which uterine contractions cause the cervix to open earlier than normal, and it can result in preterm birth. Although certain factors, such as multifetal pregnancy, may increase a woman's chances of going into preterm labor, the specific cause (or causes) is not known. If the woman knows the warning signs and symp­toms of preterm labor and seeks care early enough, should they occur, it may be possible to prevent a preterm birth. Warning signs and symptoms of preterm labor are given in the Self-Care box. Fig. 19 shows where in the body the symptoms of preterm labor may be located.

 

Patient Instructions for Self-Care How to Recognize Preterm Labor Because the onset of preterm labor is subtle and often hard to recognize, it is important to know how to feel your abdomen for uterine contractions. You can feel for contractions in the following way. While lying down, place your fingertips on the top of your uterus. A contraction is the periodic tightening or hardening of your uterus. If your uterus is contracting, you will actually feel your abdomen get tight or hard and then feel it relax or soften when the contraction is over. If you think you are having any of the other signs and symptoms of preterm labor, empty your bladder, drink three to four glasses of water for hydration, lie down tilted toward your side, and place a pillow at your back for support. Check for contractions for 1 hour. To tell how often con­tractions are occurring, check the minutes that elapse from the beginning of one contraction to the begin­ning of the next. It is not normal to have frequent uterine contractions (every 10 minutes or more often for 1 hour). Contractions of labor are regular, frequent, and hard. They also may be felt as a tightening of the abdomen or a backache. This type of contraction causes the cervix to efface and dilate. Call your doctor, nurse-midwife, clinic, or labor and birth unit, or go to the hospital if any of the following signs occur: * You have uterine contractions every 10 minutes or more often for 1 hour or * You have any of the other signs and symptoms for 1 hour or * You have any bloody spotting or leaking of fluid from your vagina It is often difficult to identify preterm labor. Accurate di­agnosis requires assessment by the health care provider, usually in the hospital or clinic. Post these instructions where they can be seen by everyone in the family.   Sexuality in Pregnancy * Be aware that maternal physiologic changes, such as breast enlargement,    nausea, fatigue, abdominal changes, perineal enlargement, leukorrhea, pelvic vasocongestion, and orgasmic responses, may affect sexuality and sexual expression. * Discuss responses to pregnancy with your partner. * Keep in mind that cultural prescriptions (dos) and proscriptions (don'ts) may affect your responses. * Although your libido may be depressed during the first trimester, it increases during the second and third trimesters. * Discuss and explore with your partner: -Alternative behaviors (e.g., mutual masturbation, foot massage, cuddling) -Alternative positions (e.g., female superior, side-lying) for sexual intercourse * Intercourse is safe as long as it is not uncomfortable. There is no correlation between intercourse and miscarriage, but observe the following precautions: -Abstain from intercourse if you experience uterine cramping or vaginal bleeding; report event to your caregiver as soon as possible. -Abstain from intercourse (or any activity that re­sults in orgasm) if you have a history of cervical in­competence, until it is corrected. * Continue to use safer sex behaviors. Women at risk for acquiring or transmitting sexually transmitted infections are encouraged to use condoms during sexual intercourse throughout pregnancy.

 

Fig. 19 Symptoms of preterm labor.

 

Sexual counseling

The sexual counseling of expectant couples includes countering misinformation, providing reassurance of nor­mality, and suggesting alternative behaviors (see Self-Care box). The uniqueness of each couple is considered within a biopsychosocial framework.

Many women merely need permission to be sexually ac­tive during pregnancy. Many other women, however, need to be given information about the physiologic changes that occur during pregnancy and have the myths associ­ated with sex during pregnancy dispelled. Such tasks are within the purview of the nurse and should be an integral component of the health care rendered (Alteneder & Hartzell, 1998).

Some couples need to be referred for sex therapy or family therapy. Couples with long-standing problems with sexual dysfunction that are intensified by pregnancy are candidates for sex therapy. Whenever a sexual problem is a symptom of a more serious relationship problem, the couple would benefit from family therapy.

Suggesting alternative behaviors. Research has not demonstrated conclusively that coitus and orgasm are con-traindicated at any time during pregnancy for the obstetri-cally and medically healthy woman (von Sydow, 1999). However, a history of more than one miscarriage, threat­ened miscarriage in the first or second trimester, and pre­mature rupture of membranes, bleeding, or abdominal pain during the third trimester warrant precaution when it comes to coitus and orgasm.

Solitary and mutual masturbation and oral-genital in­tercourse may be used by couples as alternatives to penile-vaginal intercourse. Partners who enjoy oral/vaginal sex may feel "turned off" by the normal increase in the amount and odor of vaginal discharge during pregnancy. Couples who practice oral/vaginal sex should be cau­tioned against the blowing of air into the vagina, particu­larly during the last few weeks of pregnancy when the cervix may be slightly open. An air embolism can occur if air is forced between the uterine wall and the fetal mem­branes and enters the maternal vascular system through the placenta. Multiparous women sometimes experience severe breast tenderness in the first trimester. A coital position that avoids direct pressure on the woman's breasts and de­creased breast fondling during love play can be recom­mended to such couples. The woman should also be reas­sured that this condition is normal and temporary.

Some women complain of lower abdominal cramping and backache after orgasm during the first and third trimesters. A back rub can often relieve some of the dis­comfort and provide a pleasant experience. A tonic uterine contraction, often lasting up to a minute, replaces the rhythmic contractions of orgasm during the third trimester. Changes in the fetal heart rate without fetal dis­tress have also been reported.

Showing the woman or couple pictures of possible variations of coital position is often helpful (Fig. 20). The female-superior, side-by-side, and rear-entry positions are possible alternative positions to the traditional male-superior position. The woman astride (superior position) allows her to control the angle and depth of penile pene­tration, as well as to protect her breasts and abdomen. The side-by-side position is the preferred one, especially dur­ing the third trimester, because it requires less energy and places less pressure on the pregnant abdomen.

 

Fig. 20 Positions for sexual intercourse during pregnancy. A, Female superior. B, Side by side. C, Rear entry. D, Facing each other.

 

The objective of safer sex is to provide prophylaxis against the acquisition and transmission of STIs (e.g., her­pes simplex virus, HIV). Because these diseases may be transmitted to the woman and her fetus, the use of con­doms is recommended throughout pregnancy if the woman is at risk for acquiring an STL

 

Psychosocial support

Esteem, affection, trust, concern, consideration of cul­tural and religious responses, and listening are all compo­nents of the emotional support given to the pregnant woman and her family. The woman's satisfaction with her relationships and support, her feeling of competence, and her sense of being in control are important issues to be ad­dressed in the third trimester. A discussion of fetal re­sponses to stimuli, such as sound, light, maternal posture, and tension, as well as patterns of sleeping and waking, can be helpful. Also discussed are emotional tensions that can arise in relation to the childbirth experience, such as those stemming from fear of pain, loss of control, and possible birth of the infant before reaching the hospital; anxieties about the recognized responsibilities and tasks of parent­hood; parental concerns about the safety of the mother and unborn child; parental concerns about siblings and their acceptance of the new baby; parental concerns about social and economic responsibilities; and parental concerns arising from conflicts in cultural, religious, or personal value systems. Malnory (1996) has developed guidelines that identify expected behavior and appropriate nursing in­terventions for each stage of psychosocial development in pregnancy. Such a guide promotes thorough assessment.

The father's or partner's commitment to the pregnancy, the couple's relationship, and their concerns about sexual­ity and sexual expression can emerge as issues for many ex­pectant parents. Validation, feedback, and social compari­son characterize the support given.

Providing the mother- and father-to-be an opportunity to discuss their concerns, listening carefully, and validating the normality of their responses can meet their needs to varying degrees. Nurses must also recognize that men (and female partners) feel more vulnerable during their part­ner's pregnancy. Anticipatory guidance and health promo­tion strategies can help partners cope with their concerns. Nursing intervention may either directly help them deal with such concerns in the event that such intimate feelings are confided or do so indirectly through the education of the mothers. Health care providers can stimulate and en­courage open dialogue between the couple.

Evaluation

Evaluation of the effectiveness of care of the woman dur­ing pregnancy is based on the previously stated outcomes (see Plan of Care).

 

PLAN Of CARE Discomforts of Pregnancy and Warning Signs FIRST TRIMESTER NURSING DIAGNOSIS Deficient knowledge re­lated to schedule of prenatal visits throughout pregnancy as evidenced by patient questions and concerns Expected Outcome: Patient will verbalize correct appointment schedule for the duration of the pregnancy. Nursing Interventions/Ratinales Provide information regarding schedule of visits, tests, and other assessments and interventions that will be provided throughout the pregnancy to empower patient to function in collaboration with the caregiver.   NURSING DIAGNOSIS Imbaianced nutrition: less than body requirements, related to nausea and vomiting as evidenced by patient report and weight loss Expected Outcome Patient will gain 7 to 2.5 kg during the first trimester. Nursing Interventions/Ratinales Verify prepregnant weight to plan a diet realistic according to individual patient's nutritional needs. Obtain diet history to identify current meal patterns and foods that may be implicated in nausea. Advise patient to consume small frequent meals and avoid having empty stomach to avoid further nausea episodes. Suggest that patient eat a simple carbohydrate such as dry crackers before arising in the morning to avoid empty stomach and decrease incidence of nausea and vomiting. Advise patient to call health care provider if vomiting is per­sistent and severe to identify possible incidence of hyper-emesis gravidarum.   NURSING DIAGNOSIS Fatigue related to hor­monal changes in the first trimester as evi­denced by patient complaints Expected Outcome Patient will report a decreased number of episodes of fatigue. Nursing Interventions/Ratinales Rest as needed to avoid increasing feeling of fatigue. Eat a well-balanced diet to meet increased metabolic de­mands and avoid anemia. Discuss the use of support systems to help with household responsibilities to decrease workload at home and de­crease fatigue.   SECOND TRIMESTER NURSING DIAGNOSIS Constipation related to pro­gesterone influence on Gl tract as evidenced by patient report of altered patterns of elimination Expected Outcome Patient will report a return to normal bowel elimination pattern follow/ing imple­mentation of interventions. Nursing Interventions/Ratinales Provide information to patient regarding pregnancy-related causes: progesterone slowing gastrointestinal motility, growing uterus compressing intestines, and influence of iron supplementation to provide basic information for self-care during pregnancy. Assist patient to plan a diet that will promote regular bowel movements, such as increasing amount of oral fluid intake to at least six glasses of water a day and increasing the amount of fiber in daily diet, and to maintain moderate ex­ercise to promote self-care. Reinforce for patient that she should not take any laxatives, stool softeners, or enemas without first consulting the health care provider to prevent any injuries to patient or fetus.   NURSING DIAGNOSIS Deficient knowledge re­lated to first pregnancy as evidenced by patient questions regarding possible complications of second and third trimesters Expected Outcome Patient will correctly list signs of potential complications that can occur during the second and third trimesters. Nursing Interventions/Ratinales Provide information concerning the potential complications or warning signs that can occur during the second and third trimesters, including possible causes of signs and the impor­tance of calling the health care provider immediately to ensure identification and treatment of problems in a timely manner. Provide a written list of complications to have a reference list for emergencies.   THIRD TRIMESTER NURSING DIAGNOSIS Anxiety regarding onset of labor and the processes of labor related to inex­perience as evidenced by patient questions and statement of concerns Expected Outcome Patient will verbalize basic un­derstanding of signs of labor onset, when to call the health care provider, and list resources for childbirth education. Nursing Interventions/Ratinales Provide information regarding signs of labor onset and when to call the health care provider, and give written informa­tion regarding local childbirth education classes to em­power and promote self-care and to allay anxiety.   NURSING DIAGNOSIS Disturbed sleep pattern re­lated to discomforts/insomnia of third trimester as evidenced by patient report of inadequate rest Expected Outcome Patient will report an improve­ment of quality and quantity of rest and sleep. Nursing Interventions/Ratinales Assess current sleep pattern and review need for increased requirement during pregnancy to identify need for change in sleep patterns. Suggest change of position to side-lying with pillows between legs or to sleep in semi-Fowler's position to increase sup­port and decrease any problems with dyspnea or heartburn. Reinforce the possibility of the use of various sleep aids such as relaxation techniques, reading, and decreased activity before bedtime to decrease the possibility of anxiety or physical discomforts before bedtime.