Anatomy and physiology of pregnancy

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

Prepared by assistant professor N.Petrenko, MD, PhD

 

LEARNING OBJECTIVES

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

* Describe the various types of pregnancy tests.

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

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

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

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

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

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

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

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

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

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

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

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

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

* Explain recommended maternal weight gain during pregnancy.

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

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

* Examine the role of nutrition supplements during pregnancy.

* List five nutritional risk factors during pregnancy.

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

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

 

KEY TERMS AND DEFINITIONS

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

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

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

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

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

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

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

epulis Tumorlike benign lesion of the gingiva seen in pregnant women

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

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

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

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

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

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

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

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

operculum Plug of mucus that fills the cervical canal during pregnancy

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

ptyalism Excessive salivation

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

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

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

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

 

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

 

GRAVIDITY AND PARITY

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

• Gravida—a woman who is pregnant

• Gravidity—pregnancy

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

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

• Nulligravida—a woman who has never been pregnant

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

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

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

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

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

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

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

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

 

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

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

 

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

 

PREGNANCY TESTS

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

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

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

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

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

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

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

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

 

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

 

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

ADAPTATIONS TO PREGNANCY

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

 

SIGNS OF PREGNANCY

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

 

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

 

REPRODUCTIVE SYSTEM AND BREASTS

Uterus

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

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

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

 

Fig. 1 Comparison of abdomen, vulva, and cervix iullipara

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

 

 

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

 

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

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

 

 

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

 

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

 

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

 

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

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

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

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

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

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

 

Fig. 5 Internal ballottement (18 weeks).

 

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

 

Vagina and vulva

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

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

 

Fig. 6 A, Cervix ionpregnant woman. B, Cervix during pregnancy.

 

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

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

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

 

 

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

 

Breasts

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

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

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

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

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

 

GENERAL BODY SYSTEMS

Cardiovascular system

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

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

 

 

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

 

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

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

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

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

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

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

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

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

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

Box 1 Calculation of Mean Arterial Pressure (MAP)

 

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

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

 

 

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

 

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

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

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

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

 

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

 

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

 

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

 

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

 

Respiratory system

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

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

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

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

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

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

 

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

 

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

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

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

 

Renal system

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

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

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

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

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

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

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

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

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

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

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

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

 

Integumentary system

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

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

 

 

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

 

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

 

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

 

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

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

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

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

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

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

 

Musculoskeletal system

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

 

 

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

 

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

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

 

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

 

Neurologic system

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

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

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

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

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

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

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

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

 

Gastrointestinal system

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

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

 

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

 

 

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

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

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

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

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

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

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

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

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

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

 

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

 

Endocrine system

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

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

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

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

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

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

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

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

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

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

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

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

Nursing Care During Pregnancy

 

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

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

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

DIAGNOSIS OF PREGNANCY

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

 

SIGNS AND SYMPTOMS

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

 

ESTIMATING DATE OF BIRTH

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

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

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

ADAPTATION TO PREGNANCY

Pregnancy affects all family members, and each family member must adapt to the pregnancy and interpret its meaning in light of his or her oweeds. 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 commoursing 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 caow 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 iurturing 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 es 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 withiormal 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 informa­tioecessary for adherence to health care guidelines.

The expectant womaeeds 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. Womeeed 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 relaxatioeeds. 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: ofteoted 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: ofteoted 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 mediaerve 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 womaeeds 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 thaormal, 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 iausea. 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.

 

VARIATIONS IN PRENATAL CARE

The course of prenatal care described thus far may seem to suggest that the experiences of childbearing women are sim­ilar and that nursing interventions are uniformly consistent across all populations. Although typical patterns of re­sponse to pregnancy are easily recognized and many aspects of prenatal care indeed are consistent, pregnant women en­ter the health care system with individual concerns and needs. The ability of the nurse to assess unique needs and to tailor interventions to the individual are hallmarks of exper­tise in providing care. Variations that influence prenatal care include culture, age, and number of fetuses.

 

CULTURAL INFLUENCES

Prenatal care in the United States reflects the Western bio-medical model of care, in which women are encouraged to seek prenatal care as early as possible in their pregnancy by visiting a physician, nurse-midwife, or office or clinic. Such visits are usually routine and follow a systematic se­quence, with the initial visit followed by monthly, then semimonthly, then weekly visits. Monitoring weight and blood pressure; testing blood and urine; teaching specific information about nutrition, rest, and activity; and prepar­ing for childbirth are common components of prenatal care. This model is not only unfamiliar but seems strange and unnecessary to many groups.

Many cultural variations in prenatal care exist. Even if the prenatal care described is familiar to a woman, some practices may conflict with the beliefs and practices of a subculture group to which she belongs. Because of these and other factors, such as lack of money, lack of trans­portation, and poor communication on the part of health care providers, women from many such groups do not par­ticipate in the prenatal care system. Such behavior may be misinterpreted by nurses as uncaring, lazy, or ignorant.

A concern for modesty is also a deterrent to many women in seeking prenatal care. For some women, expos­ing body parts, especially to a man, is considered a major violation of their modesty. Thus many women prefer a fe­male to a male health care provider. For some women, in­vasive procedures, such as a vaginal examination, may be so threatening that they cannot be discussed, even with their own husbands. Most women value and appreciate ef­forts to maintain their modesty.

In many cultural groups a physician is deemed appro­priate only in times of illness, and because pregnancy is considered a normal process and the woman is in a state of health, the services of a physician are considered inap­propriate. Even if problems with pregnancy do develop from the standpoint of Western medicine, they may not be perceived as problems but considered normal by members of these cultural groups.

Although pregnancy is considered normal by many, certain practices are expected of women of all cultures to ensure a good outcome. Cultural prescriptions tell women what to do, and cultural proscriptions establish taboos. The purposes of these practices are to prevent ma­ternal illness resulting from a pregnancy-induced imbal-anced state and to protect the vulnerable fetus. Prescrip­tions and proscriptions regulate the woman’s emotional response, clothing, activity and rest, sexual activity, and di­etary practices (Purnell & Paulanka, 1998).

To provide culturally sensitive care, the nurse must be knowledgeable about practices and customs, although it is not possible to know all there is to know about every culture and subculture, as well as the many lifestyles that exist. The nurse can question patients about cultural beliefs and child-bearing, and the nurse can support and nurture those beliefs that promote physical or emotional adaptation. However, if potentially harmful beliefs are identified, the nurse should carefully provide education and propose modifications.

Emotional response

Virtually all cultures emphasize the importance of maintaining a socially harmonious and agreeable environ­ment for a pregnant woman. An absence of stress is im­portant in ensuring a successful outcome for the mother and baby. Harmony with other people must be fostered, and visits from extended family members may be required to demonstrate pleasant and noncontroversial relation­ships. If discord exists in a relationship, it is usually dealt with in culturally prescribed ways.

Besides proscriptions regarding food, other proscrip­tions involve imitative magic. For example, some Mexi­cans believe pregnant women should not witness an eclipse of the moon because it may cause a cleft palate in the infant. They also believe that exposure to an earth­quake may precipitate preterm birth, miscarriage, or even a breech presentation. In some cultures a pregnant woman must not ridicule someone with an affliction for fear her child might be born with the same handicap. A mother should not hate a person lest her child resemble that per­son, and dental work should not be done because it may cause a baby to have a “harelip.” A widely held folk belief in many cultures is that the pregnant woman should re­frain from raising her arms above her head and tying knots so that the umbilical cord does not wrap around the baby’s neck or knot. Other cultures believe placing a knife under the bed of a laboring woman will “cut” her pain.

Clothing

Although most cultural groups do not prescribe specific clothing to be worn during pregnancy, modesty is an ex­pectation of many. Some Mexican women of the South­west wear a cord beneath the breast and knotted over the umbilicus. This cord, called a muneco, is thought to pre­vent morning sickness and ensure a safe birth. Amulets, medals, and beads may also be worn to ward off evil spir­its (Spector, 1996).

Physical activity and rest

Norms that regulate the physical activity of mothers during pregnancy vary tremendously. Many groups, in­cluding Native Americans and some Asian groups, en­courage women to be active, to walk, and to engage ior­mal although not strenuous activities to ensure that the baby is healthy and not too large. On the other hand, other groups such as the Filipino culture believe that any activity is dangerous, and others willingly take over the work of the pregnant woman. Some Filipinos believe that this inactivity protects the mother and child. The mother is encouraged simply to produce the succeeding genera­tion. If health care providers do not know of this belief, they could misinterpret this behavior as laziness or non-compliance with the desired prenatal health care regimen. Again, it is important for the nurse to find out the way each pregnant woman views activity and rest.

Sexual activity

In most cultures, sexual activity is not prohibited until the end of pregnancy. Mexicans commonly view sexual ac­tivity as necessary to keep the birth canal lubricated. On the other hand, some Vietnamese may have definite pro­scriptions against sexual intercourse, requiring abstinence throughout the pregnancy because it is thought that sexual intercourse may harm the mother and fetus.

Diet

Nutritional information given by Western health care providers may also be a source of conflict for many cultural groups, but such a conflict commonly is not known by the health care providers unless they understand the dietary be­liefs and practices of the particular people for whom they are caring. For example, Muslims must eat meat slaugh­tered in accordance with Muslim law. If this is not possible, they will accept Kosher or vegetarian foods. Many cultures permit pregnant women to eat only warm foods.

 

AGE DIFFERENCES

The age of the childbearing couple may have a significant in­fluence on their physical and psychosocial adaptation to pregnancy. Normal developmental processes that occur in both very young and older mothers are interrupted by preg­nancy and require a different type of adaptation to pregnancy than that of the woman of typical childbearing age. Although the individuality of each pregnant woman is recognized, spe­cial needs of expectant mothers 15 years of age or younger and those 35 years of age or older are summarized next.

Adolescent mothers

Approximately 1 million adolescents in the United States become pregnant each year (Alan Guttmacher Insti­tute [AGI], 1999). Most of the pregnancies are unin­tended, and nearly 30% end in elective abortion. Never­theless, adolescents are responsible for almost 500,000 births in the United States annually (Ventura et al., 1998). Hispanic and African-American adolescents have the highest birthrate. Of girls who become pregnant, one in six will have a repeat pregnancy within 1 year (Cockey, 1997). Most of these young women are unmarried, and many are not ready for the emotional, psychologic, and financial re­sponsibilities of parenthood.

Despite these alarming statistics and the fact that the United States has the highest adolescent birthrate in the industrialized world, the birthrate for adolescents has steadily declined since 1991 (Ventura et al, 1998). Con­centrated national efforts have spawned a host of adoles­cent pregnancy prevention programs that have had vary­ing degrees of success. Characteristics of programs that make a difference are those that have sustained commit­ment to adolescents over a long period of time, involve the parents and other adults in the community, promote abstinence and personal responsibility, and assist adoles­cents to develop a clear strategy for reaching future goals such as a college education or a career (Cockey, 1997).

When adolescents do become pregnant and decide to give birth, they are much less likely than older women to receive adequate prenatal care, with many receiving no care at all (Ventura et al., 1998). These young women also are more likely to smoke and less likely to gain adequate weight during pregnancy. As a result of these and other factors, babies born to adolescents are at greatly increased risk of LBW, of serious and long-term disability, and of dy­ing during the first year of life.

Delayed entry into prenatal care may be the result of late recognition of pregnancy, denial of pregnancy, or confusion about the services that are available. Such a delay in care may leave an inadequate time before birth to attend to cor­rectable problems.

The very young pregnant adolescent is at higher risk for each of the confounding variables associated with poor pregnancy outcomes (e.g., socioeconomic factors) and for those conditions associated with a first pregnancy regardless of age (e.g., PIH). However, when prenatal care is initiated early and consistently, and confounding variables are controlled, very young pregnant adolescents are at no greater risk (nor are their infants) for an adverse outcome than older pregnant women. The role of the nurse in re­ducing the risks and consequences of adolescent pregnancy is thus twofold: first, to encourage early and continued pre­natal care (Fig. 21); and second, to refer the adolescent, if necessary, for appropriate social support services, which can help reverse the effects of a negative socioeconomic envi­ronment (Harner, Burgess, & Asher, 2001).

 

Fig. 21 Pregnant adolescents reviewing fetal develop­ment. (Courtesy Marjorie Pyle, FSNC, Lifecircle, Costa Mesa, CA.)

 

Older mothers

Two groups of older parents have emerged in the pop­ulation of women having a child late in their childbearing years. One group consists of women who have many chil­dren or who have a child during the menopausal period. The other group consists of relative newcomers to mater­nity care. These are women who have deliberately delayed childbearing until their late thirties or early forties.

Multiparous mothers. Multiparous women may be those who have never used contraceptives because of per­sonal choice or lack of knowledge concerning contracep­tives, or they may be women who have used contracep­tives successfully during the childbearing years but, as menopause approaches, they may cease menstruating reg­ularly or stop using contraceptives while remaining sexu­ally active and consequently become pregnant. The older multiparous woman may feel that pregnancy separates her from her peer group and that her age is a hindrance to close associations with young mothers. Other parents wel­come the unexpected infant as evidence of continuing ma­ternal and paternal roles.

Primiparous mothers. The number of first-time preg­nancies in women between ages 35 and 40 years has in­creased significantly over the past 10 years. It is not un­commoow to see women in their late thirties or even in their early forties pregnant for the first time. Reasons for delaying pregnancy include advanced education, career priorities, better contraceptive measures, and infertility.

These women choose parenthood as opposed to a child-free lifestyle. They often are successfully established in a career and a lifestyle with a partner that includes time for self-attention, the establishment of a home with accumu­lated possessions, and freedom to travel. When asked the reason they chose pregnancy later in life, many reply, “Be­cause time is running out.”

The dilemma of choice includes the recognition that being a parent will have positive and negative conse­quences. Couples need to discuss the consequences of childbearing and child rearing before committing them­selves to this lifelong venture. Partners in this group seem to share the preparation for parenthood, planning for a family-centered birth, and desire to be loving and compe­tent parents. However, the reality of child care may prove difficult for such parents.

As with mothers of all ages, the mother older than 35 who is accustomed to the stimulation of contact with other adults may find the isolation with her infant difficult to accept. Anger and resentment toward the father (or in­fant) can result, even with “preparation” for these aspects of parenting.

First-time mothers older than 35 years select the “right time” for pregnancy; this right time is influenced by their awareness of the increasing possibility of infertility or of ge­netic defects in the infants of older women. Such women seek information about pregnancy from books and friends. They actively try to prevent fetal disorders and are careful in searching for the best possible maternity care. They iden­tify sources of stress in their lives. They have concerns about having enough energy and stamina to meet the de­mands of parenting and their new roles and relationships.

If they become pregnant after treatment for infertility, they may suddenly have negative or ambivalent feelings about the pregnancy. They may experience a multifetal pregnancy that may create emotional and physical prob­lems. Adjusting to parenting two or more infants requires adaptability and additional resources.

During pregnancy, parents explore the possibilities and responsibilities of changing identities and new roles. They must prepare a safe and nurturing environment during pregnancy and after birth. They must integrate the child into an established family system and negotiate new roles (parent roles, sibling roles, grandparent roles) for family members.

Adverse perinatal outcomes are more common in older primiparas than in younger women even when they re­ceive good prenatal care. Dollberg and colleagues (1996) reported that women 35 years of age and older are more likely than younger primiparas to have LBW infants, pre­mature birth, IUGR, and abruptio placentae. The inci­dence of malpresentation also is more common in older primiparas, and they are more likely to have a cesarean birth. The occurrence of these complications is stressful for the new parents, and nursing interventions that pro­vide information and psychosocial support are needed, as well as care for physical needs. In uncomplicated pregnan­cies, older mothers have significantly less fear of helpless­ness and loss of control in labor than younger women (Stark, 1997). Age and education are thought to balance the concerns of older mothers related to age.

Multifetal pregnancy

A multifetal pregnancy places the mother and fetuses  risk. The maternal blood volume is increased, resulting in an increased strain on the maternal cardiovascular system. Anemia often develops because of a greater demand for iron by the fetuses. Marked uterine distention and in­creased pressure on the adjacent viscera and pelvic vascula-ture and diastasis of the two recti abdominis muscles (in the midline) may occur. Placenta previa develops more com­monly in multifetal pregnancies because of the large size or placement of the placentas. Premature separation of the placenta may occur before the second and any subsequent fetuses are born. The incidence of pregnancy-induced hy­pertension is increased (Cunningham et al., 2001).

Multifetal pregnancies often end in preterm birth. Spontaneous rupture of membranes before term is com­mon. Congenital malformations are twice as common in monozygotic twins as in singletons, though there is no increase in the incidence of congenital anomalies in dizy gotic twins. In addition, two-vessel cords-that is, cords with a single umbilical artery—occur more often in twins than in singletons, but this abnormality is most common in monozygotic twins. However, the most serious problem for the fetus is the local shunting of blood between pla­centas (twin-to-twin transfusion), causing the recipient twin to be larger and the donor twin to be small, pallid, de­hydrated, malnourished, and hypovolemic. In addition, congenital heart failure may develop in the larger twin dur­ing the first 24 hours after birth.

The clinical diagnosis of multifetal pregnancy is accurate in approximately 90% of cases. The likelihood of a multife­tal pregnancy is increased if any one or a combination of the following factors is revealed during a careful assessment:

* History of dizygous twins in the female lineage

* Use of fertility drugs

* More rapid uterine growth for time in pregnancy

* Hydramnios

* The palpation of an excessive number of small or large parts Asynchronous fetal heartbeats or more than one fetal electrocardiographic tracing

* Ultrasonographic evidence of more than one fetus.

The diagnosis of a twin pregnancy can come as a shock to many expectant parents, and they may need additional support and education to help them cope with the changes they face. The mother will need nutrition counseling so that she gains more weight than that needed for a single­ton pregnancy, counseling that maternal adaptations will probably be more uncomfortable, and information about the possibility of a preterm birth.

If the presence of more than three fetuses is diagnosed, the parents may receive counseling regarding selective re­duction of the pregnancies to reduce the incidence of pre­mature birth and improve the opportunities for growth to term gestation for the remaining infants (Berkowitz, 1998). This situation poses an ethical dilemma for many couples, especially those who have worked hard to over­come problems with infertility and harbor strong values regarding right to life. The nurse who is able to engage the couple in discussion to identify what resources could help the couple (e.g., a minister, priest, or mental health coun­selor) can make the process of making a decision some­what less traumatic.

The prenatal care given women with multifetal preg­nancies includes changes in the pattern of care and modi­fications in other aspects such as the amount of weight gained and the diet observed. The prenatal visits of these mothers are scheduled at least every 2 weeks in the second trimester and weekly thereafter. No specific recommenda­tion for weight gain for women with multifetal pregnan­cies has been made. In twin gestations, reports of gains of 20 kg have been associated with positive outcomes. Iron and vitamin supplementation is desirable. Attempts are made to prevent preeclampsia and eclampsia, which occur

more commonly during multifetal pregnancies, and vaginitis; if they cannot be prevented, they are treated.

The considerable uterine distention involved can cause the backache commonly experienced by pregnant women to be even worse. Elastic stockings or maternity tights may be worn to control leg vancosities. If there are risk factors for preterm birth (e.g., premature dilation of the cervix), abstinence from orgasm and nipple stimulation during the last trimester is recommended to help avert preterm labor. Frequent ultrasound examinations and heart rate monitor­ing will occur. Some practitioners recommend bed rest be­ginning at 20 weeks in women carrying twins to prevent preterm labor. Other practitioners question the value of prolonged bed rest because of the potential adverse physi­ologic effects on the woman and better pregnancy out­comes have not occurred (Cunningham et al., 2001). If bed rest is recommended, the mother needs to assume a lateral position to promote increased placental perfusion. If birth is delayed until after the thirty-sixth week, the risk of morbidity and mortality for the neonates decreases.

Multiple newborns will likely place a strain on finances, space, workload, and the mother’s and family’s coping ca­pability. Lifestyle changes may be necessary. Parents will need assistance in making realistic plans for the care of the babies, for example, whether to breastfeed and whether to raise them as “alike” or as separate persons. Parents should be referred to national organizations such as Parents of Twins, Mothers of Multiples, and the La Leche League for further support (see Resources at end of chapter).

CHILDBIRTH EDUCATION

The goal of childbirth education is to assist individuals and their family members to make informed decisions about pregnancy, birth, and parenthood. To accomplish this goal, the woman and her family need knowledge of the components of a healthy pregnancy, the process of la­bor and birth, and coping strategies to deal with the chal­lenges of parenthood. Education for family members should begin before pregnancy and continue through the postpartum period.

Once a family has decided to have a baby, the next de­cisions involve choosing a care provider, type of care, and the place for birth; choices about infant feeding and care will follow. If a woman has had a previous cesarean birth, she may consider the possibility of a vaginal birth. This section discusses these considerations and the nurse’s role in educating childbearing families so that family members can make informed decisions about their choices.

 Most childbirth education classes are attended by the pregnant woman and her partner, although a friend, teenage daughter, or parent may be the selected support person (Fig. 22). Classes may be offered for grandparents and siblings to prepare them for their attendance at birth or the arrival of the baby. Classes focus on preparing fam­ilies intellectually, emotionally, and physically for child-birth, and promote wellness and improved lifestyle behav­iors during the childbearing years.

Fig. 22 Learning relaxation exercises with the whole family. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

 

Previous pregnancy and childbirth experiences are im­portant influences on current learning needs. The woman’s (and support person’s) age, cultural background, socioeconomic status, spiritual beliefs, personal philoso­phy of childbirth, and learning styles need to be assessed to develop an individualized teaching plan.

 

CHILDBIRTH EDUCATION PROGRAMS

Expectant parents and their families are recognized as hav­ing different interests and needing different information as the pregnancy progresses. Consequently such programs are designed to meet the informational needs of parents during the three major stages of pregnancy and after birth—first-trimester classes, second-trimester classes, third-trimester classes, and postpartum (“fourth-trimester”) classes.

First-trimester (“early bird”) classes provide fundamental information and focus on the following topics: (1) early fe­tal development; (2) physiologic and emotional changes that occur early in pregnancy; (3) human sexuality; (4) birth settings and types of health care providers; (5) rest, exercise, and measures for relieving common discomforts; (6) the nutritional needs of the mother and fetus; and (7) the de­velopment of a birth plan. Environmental and workplace hazards have become important concerns in recent years, so even though pregnancy is considered a normal process, exercises, warning signs, drugs, and self-medication are top­ics of interest and concern.

Second-trimester classes emphasize the woman’s partic­ipation in self-care and provide information about prepara­tion for breastfeeding and formula feeding; basic hygiene; common complaints and simple, safe remedies; continued fetal development; infant health; and parenting. Support systems that are available during pregnancy and after birth are discussed throughout the series of classes. Such support systems can help parents function independently and ef­fectively. During all the classes, participants are encouraged to openly express their feelings and concerns about any as­pect of pregnancy, birth, and parenting.

During the third trimester, childbirth education focuses on preparation for the experiences of labor and birth. The methods of childbirth preparation that are often the basis for prenatal classes include the Dick-Read, Lamaze, and Bradley methods. Breathing and relaxation techniques are essential to these methods (see Chapter 12 for further discussion).

All three methods incorporate intellectual and physical components. In addition, all emphasize the naturalness of childbirth and, at least to some extent, empowering women to make choices for themselves. Each program ed­ucates women to exchange fear of the unknown for confi­dence and understanding. Adequate prenatal education in­cludes information on maternal adaptation, nutrition, sexuality, basic hygiene, and labor and birth. Support for the woman in labor is provided by her husband or another support person chosen by the expectant mother.

Pain management

Fear of pain is a key issue for pregnant women and a rea­son many give for attending childbirth education classes. Physiologic responses to labor pain and effects of length of labor and anesthesia/analgesia on mother and infant vary but can interfere with the normal progress of labor.

Pain management strategies are an essential compo­nent of childbirth education. Some women or couples want primarily to learn what to expect from medications. Others have a strong desire to use their own resources to manage labor discomfort. Couples need information about the advantages and disadvantages of pain medica­tion and other techniques for coping with labor. Al­though neither partner should feel guilty if pain medica­tion is required during a particular labor experience, an emphasis on nonpharmacologic pain management strate­gies helps couples manage the labor and birth with dig­nity and increased comfort. Most childbirth instructors teach a flexible approach, which helps couples learn and master many techniques that can be used during labor. Women are encouraged to incorporate their natural re­sponses into coping with the pain of labor and birth. Couples are taught gate-control techniques such as mas­sage, pressure on the palms or soles of the feet, hot com­presses to the perineum, perineal massage, applications of heat or cold, breathing patterns, and focusing of attention on visual or other stimuli as ways to increase coping and decrease the distress from labor pain. Relaxation tech­niques are also taught. (See Chapter 12 for further discus­sion of methods of managing pain.)

Current practices

A variety of approaches to childbirth education have evolved as educators attempt to meet learning needs. In addition to classes designed specifically for pregnant adolescents and their partners or parents, classes have begun for other groups with special learning needs, such as first-time mothers older than 35, single women, adoptive par­ents, and parents of twins or multiples. Refresher classes for parents with children review coping techniques for la­bor and birth and help couples prepare for sibling reac­tions and adjustments to a new baby. One-day classes have been developed for women who work, women and part­ners who have conflicting schedules or who have careers that require travel, or women who just want the basics (Bridgwater & Wiman, 1998). Cesarean birth classes are of­fered for couples who may be at risk for an operative birth. Because many women successfully give birth vaginally af­ter a previous cesarean birth, some classes focus on vaginal birth after cesarean (VBAC).

Because of the multicultural composition of the popu­lation, great diversity exists in attitudes, expectations, and behaviors judged appropriate during pregnancy and early parenthood. No one approach can meet all needs. For ex­ample, classes for new immigrants are particularly effective when taught in the class members’ primary language. For classes to be meaningful, childbirth educators must under­stand the value systems in other cultures and their influ­ence on issues such as nutrition, early prenatal care, ma­ternal weight gain, and infant feeding practices. Parent educators must establish rapport, be understood, and build on cultural practices, reinforcing the positive and promoting change only if a practice is directly harmful.

OPTIONS FOR CHILDBEARING FAMILIES

BIRTH PLAN

The birth plan is a tool by which parents can explore their childbirth options and choose those that are most impor­tant to them. Many parents already indicate some of their preferences by the type of health care provider and birth setting (hospital, birth center, or home) they have chosen. Some pregnant women enlist the services of a health care provider only after an interview and a tour of the birth fa­cility. Others do not give conscious thought to the con­duct of their pregnancies, the labor and birth process, re­covery, and early parenthood. These women may need help with decision making.

Patients’ expectations must be reasonable and in keep­ing with the resources available in the community. The nurse can provide couples with pertinent information so that they can make informed decisions, alerting them to various options and the advantages and consequences of each. Some health care providers provide birth plan lists. A discussion of the printed list can serve as a means of get­ting couples to start thinking about, discussing, and iden­tifying what is personally important to them. However, it is important to remember that some options may be ap­propriate only for low risk women. The options of women with a high risk pregnancy or those in whom complications develop during labor may be severely limited, but as many choices as possible should be incorporated.

The birth plan can serve as a means of open communi­cation between the pregnant woman and her partner and between the couple and health care providers. Topics for discussion and decision making may include but are not limited to those listed in Box 4.

 

Box 4 Birth Plan TOPICS FOR DISCUSSION AND DECISIONS TO MAKE Care provider: Nurse-midwife? Obstetrician? Family physician? Independent midwife? Family/partner’s participation: Attend prenatal visits? Childbirth/parent education classes? Present during labor? During birth? During cesarean birth? Birth setting: Hospital delivery room or birthing room (if available)? A birthing center? Home? Labor management: Would you like to walk around during labor? Use a rocking chair? Use a shower? Use a Jacuzzi, if available? Use a birthing ball? Be interested in having music or dimmed lighting? Have ice or fluids as desired? Have solid foods if allowed? Use different positions for labor—on side, hands and knees, kneeling, etc.? Use a doula? Medical interventions: Have minimal internal examinations? Labor stimulation, if needed? Fetal monitoring —intermittent or continuous? Medication for pain- intravenous or epidural? Birth: Have you considered the various positions for birth—side lying? On hands and knees, kneeling, or squatting? Use a birthing bed? Delivery table? Birthing chair/stool? Water birth if available? Will you be photographing, videotaping, or recording any of the labor or birth? Who would you like to be present- partner, older siblings, other family members, or friends? What do you know about forceps- or vacuum- assisted births? Episiotomies? Will your partner want to cut the umbilical cord? Immediately after birth: Do you want to hold the baby right away? To breastfeed immediately? To delay prophylaxis eye treatment until family has had time to get acquainted with the infant? Newborn care: What about circumcision for your baby (if male)? Will the baby be breastfed or bottlefed? Postpartum care: Do you want to keep baby with you all the time or have some time for baby to go to nursery while you rest? Would you like to attend self-care or infant care classes or prefer to get such information from videotapes? On which subjects?

 

CARE PROVIDER

Often, the first decision the woman makes is who will be her primary health care provider for the pregnancy and birth. This decision is doubly important because it usually affects where the birth will take place. The nurse can pro­vide information about the different types of health care

providers and the kind of care to expect from each type. Physicians (obstetricians and family practice physicians) attend approximately 93% of births in the United States and Canada (Ventura et al., 1998). They see low risk and high risk patients. Care often includes pharmacologic and medical management of problems and the use of techno­logic procedures. Family practice physicians may need backup by obstetricians if a specialist is needed for a prob­lem such as a cesarean birth. Most physicians manage births in a hospital setting.

Nurse-rmdwives are registered nurses with additional ed­ucation and training in the care of obstetric patients. They provide care for approximately 6% of the births in the United States and Canada (Ventura et al., 1998). Nurse-midwives may practice with physicians or independently with an arrangement for physician backup. They usually see low risk obstetric patients. Care is ofteoninterventional, and the woman and family are usually encouraged to be ac­tive participants in the care. Nurse-midwives must refer pa­tients who have complications to physicians. Most births are managed in hospital settings or alternative birth centers; a small percentage may be managed in a home setting.

Independent midwives (also called lay midwives) are nonprofessional caregivers. Their training varies greatly, from formal training and certification to self-teaching. They manage approximately 1% of births in the United States and Canada (Ventura et al., 1998). Their patients who develop pregnancy problems need to be seen by a physician. Almost all births managed by lay midwives oc­cur in the home setting; that is usually the couple’s reason for choosing a lay midwife as a health care provider.

 

DOULAS

A doula is professionally trained to provide labor support, including physical, emotional, and informational support to women and their partners during labor and birth. The doula does not get involved with clinical tasks (Doulas of North America, 1999a, 1999b). A doula typically meets with the mother and her partner before labor. At this meeting, she learns the woman’s expectations and desires for the birth experience. Using this information as her guide, the doula focuses her efforts on assisting the woman to achieve her goals during labor and birth. Doulas work collaboratively with other health care providers and the partner or other supportive individuals, but their primary goal is assisting the woman (Manning-Orensteing, 1998). Doulas may be found through community contacts, other health care providers, or childbirth educators (see Re­source list at end of chapter).

 

BIRTH SETTING

With careful thought, the concept of family-centered ma­ternity care can be implemented in any setting. The three primary options of birth settings today are the hospital, an alternative birth center, and home. Women consider sev­eral factors in choosing a setting for childbirth, including the preference of their health care provider, characteristics of the birthing unit, and preference of their third-party payer.

Hospital

Approximately 99% of all births in the United States take place in a hospital setting (Ventura et al., 1998). How­ever, the types of labor and birth services vary greatly, from the traditional labor and delivery rooms with separate postpartum and newborn units to in-hospital birthing cen­ters where all or almost all care takes place in a single unit.

Labor, delivery, recovery (LDR) and labor, delivery, re­covery, postpartum (LDRP) rooms offer families a com­fortable, private space for childbirth. Women are admitted to LDR units, labor and give birth, and spend the first 1 to 2 hours there for immediate postpartum recovery and for having time with their families to bond with their new-borns. After this period of recovery, the mothers and new-borns are transferred to a postpartum unit and nursery or mother-baby unit for the duration of their stay. Care is provided by different nursing staff (e.g., labor and delivery nurses, postpartum nurses, nursery nurses). In some hospi­tals, the same nurse provides care for both mothers and newborns.

In LDRP units, total care is provided from admission for labor through postpartum discharge in the same room, usually by the same nursing staff. The woman and her family may stay in this unit for 6 to 48 hours after giving birth.

Both units are equipped with fetal monitors, emergency resuscitation equipment for both mother and newborn, and heated cribs or warming units for the newborn. Often, this equipment is in cabinets or closets when it is not being used.

Birth centers

Birth centers are usually built in locations separate from the hospital but may be located in close proximity in case transfer of the woman or newborn is needed. These birth centers are intended to offer families an alternative to home or hospital birth, providing a third choice that is a safe and cost-effective compromise. The centers are usually staffed by nurse-midwives or physicians who also have privileges at the local hospital. Patients are evaluated care­fully as a measure to ensure that only women who are at low risk for complications are included for care.

Birth centers typically have homelike accommodations, including a double bed for the couple and a crib for the newborn (Fig. 23). Emergency equipment is available but often stored out of view. Many centers have an early labor lounge or a living room, and a small kitchen may be available. The family is admitted to the birth center for la­bor and birth and will remain there until discharge, often within 6 hours of the birth. Other services provided by birth centers include those necessary for safe management during the childbearing cycle such as attendance at childbirth and parenting classes. Expectant families develop birth plans for the practices and procedures they would like to include in or exclude from their childbirth experi­ence. Patients must understand when situations may re­quire transfer to a hospital and must have agreed to abide by those guidelines.

 

Fig. 23 Birth center. A, Note double bed and crib in homelike surroundings. B, Lounge and kitchen. (Courtesy Michael S. Clement, MD, Mesa, AZ.)

 

Birth centers may have resources such as a lending li­brary for parents, reference files on related topics, recycled maternity clothes and baby clothes and equipment, and supplies and reference materials for childbirth educators. The centers may also have referral files for community re­sources that offer services related to childbirth and early parenting, including support groups (e.g., single parents, postbirth support group, parents of twins), genetic coun­seling, women’s issues, and consumer action. These cen­ters are often close to a major hospital so that quick trans­fer to that institution is possible wheecessary. Ambulance service and emergency procedures must be readily available. Fees vary with the services provided but typically are less than or equal to those charged by local hospitals. Some centers base fees on the ability of the fam­ily to pay (reduced-fee sliding scale). Several third-party payers, Medicaid, and TRICARE/CHAMPUS (the armed services insurance) recognize and reimburse these centers. However, patients should check with their health care pay­ers regarding reimbursement for prenatal care and birth in a birth center.

 

Homo birth

Home birth has always been popular in countries such as Sweden and the Netherlands. In developing countries, hospitals or adequate lying-in facilities are often unavailable to most pregnant women and home birth is a necessity.

National groups supporting home birth are the Home Oriented Maternity Experience (HOME) and the National Association of Parents for Safe Alternatives in Childbirth (NAPSAC). These groups work to foster more humane child-bearing practices at all levels, integrating the alternatives for childbirth to meet the needs of the total population. The lit­erature on childbirth demonstrates that medically directed home birth services with skilled nurse-midwives and medical backup have statistically excellent outcomes.

One advantage of home birth is that the family is in control of the experience. Another is that the birth may be more physiologically natural in familiar surroundings. The mother may be more relaxed than she would be in the hos­pital environment. The family can assist in and be a part of the birth, and mother-infant and father (partner)-infant (and sibling-infant) contact is immediate and sustained. In addition, home birth may be less expensive than a hospi­tal confinement. Serious infection may be less likely, as­suming strict aseptic principles are followed, because people generally are relatively immune to their own home bacteria.

Although some physicians, nurse-midwives, and nurses support home births that use good medical and emergency backup systems, many regard this practice as exposing the mother and fetus to unnecessary danger. Thus home births are not widely accepted by the medical community in the United States, making it difficult for a family to find a qualified health care provider to give prenatal care and at­tend the birth. Also, backup emergency care by a physician in a hospital may be difficult to arrange in advance. If an emergency delivery is necessary, no effective way to do this rapidly exists in the home setting.

Most health care providers agree that if home birth is the woman’s choice, certain criteria must be met for a safe home birth experience. The woman must be comfortable with her decision to have her baby at home. She should be in good health. Home birth is not indicated for women with a high risk pregnancy, such as when the woman has diabetes, heart disease, or preeclampsia. A drive to the hos­pital (if needed) should take no more than 10 to 15 min­utes. Finally, the woman should be attended by a well-trained physician or midwife with adequate medical supplies and resuscitation equipment, including oxygen.

MATERNAL AND FETAL NUTRITION

Nutrition is one of the many factors that influence the outcome of pregnancy (Fig. 1). However, maternal nutritional status is an especially significant factor, both because it is potentially alterable and because good nutrition before and during pregnancy is an important preventive measure for a variety of problems. These problems include birth of low-birth-weight (LBW) and preterm infants. It is essential that the importance of good nutrition be emphasized to all women of childbearing potential. Nutrition assessment, intervention, and evaluation must be an integral part of nursing care for all pregnant women.

 

Fig, 1 Web of influences that can affect outcome of pregnancy. (From Wardlaw, G., & Insel, P. [1993]. Perspectives iutrition. St. Louis: Mosby.)

NUTRIENT NEEDS BEFORE CONCEPTION

A healthful diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folic acid (folate) intake is of particular concern before conception and during early gestation, because neural tube defects (i.e., failure of the neural tube to close) are more common in infants of women with poor folic acid intake. It is estimated that the incidence of neural tube defects could be halved if all women had an adequate folic acid intake during this period (Butterworth & Bendich, 1996). All women capable of becoming pregnant are advised to consume 400 p,g of folic acid daily in fortified foods (e.g., ready-to-eat cereals and enriched grain products) or supplements, in addition to a diet rich in folic acid-containing foods: green leafy vegetables, whole grains, and meats.

Both maternal and fetal risks in pregnancy are increased when the mother is significantly underweight or overweight when pregnancy begins. Ideally, all women would achieve their desirable body weights before conception.

NUTRIENT NEEDS DURING PREGNANCY

Nutrient needs are determined, at least in part, by the stage of gestation in that the amount of fetal growth varies during the different stages of pregnancy. During the first trimester the synthesis of fetal tissues places relatively few demands on maternal nutrition. Therefore, during the first trimester, when the embryo/fetus is very small, the needs are only slightly increased over those before pregnancy. In contrast, the last trimester- is a period of noticeable fetal growth when most of the deposition of fetal stores of energy sources and minerals occurs. Basal metabolic rates, when expressed as kilocalories (kcal) per minute, are approximately 20% higher in pregnant women than ionpregnant women. This increase includes the energy cost for tissue synthesis.

Dietary reference intakes (DRIs) are a new approach that the Food and Nutrition Board of the National Academy of Sciences has adopted to provide new nutritional recommendations for the people of the United States; Health Canada is also involved in this effort (Yates, Schlicker, & Suitor, 1998). The DRIs consist of recommended dietary allowances (RDAs) and adequate intakes (AIs), as well as guidelines for avoiding excessive nutrient intakes. RDAs are recommendations for daily nutritional intakes that meet the needs of almost all of the healthy members of the population. AIs are similar to the RDAs except that they are used when there are not enough data available to be certain that they meet the needs of the healthy population. The RDAs and the AIs include a wide variety of nutrients and food components, and they are divided into age, sex, and life-stage categories (e.g., infancy, pregnancy, lactation). They can be used as goals in planning the diets of individuals (Table 1).

TABLE 10-1 Nutritional RBcommendations During Pregnancy and Lactation
NUTRIENT (UNIT)	RECOMMENDATION FOR NONPREGNANT FEMALE*	RECOMMENDATION FOR PREGNANCY*	RECOMMENDATION FOR LACTATION*	ROLE IN RELATION TO PREGNANCY AND LACTATION	FOOD/FOOD SOURCES
Energy	Variable	First trimester, same as nonpregnant; second and third trimesters, nonpregnant + 300	Nonpregnant+ 500	Growth of fetal and maternal issues; milk production	Carbohydrate, fat, protein
Protein	50	60	65	Synthesis of the products of conception; growth of maternal tissue and expansion of blood volume; secretion of milk protein during lactation	Meats, eggs, cheese, yogurt, legumes (dry beans and peas, peanuts), nuts, grains
MINERALS
Calcium (mg)	1300/1000	1300/1000	1300/1000	Fetal and infant skeleton and tooth formation; maintenance of maternal bone and tooth mineralization	Milk, cheese, yogurt, sardines or other fish eaten with bones left in, deep green leafy vegetables except spinach or Swiss chard, tofu, baked beans
Phosphorus (mg)	1250/700	1250/700	1250/700	Fetal and infant skeleton and ooth formation	Milk, cheese, yogurt, meats, whole grains, nuts, legumes
Iron (mg)	15	30	15	Maternal hemoglobin formation, fetal liver iron storage	Liver, meats, whole or enriched breads and cereals, deep green leafy vegetables, legumes, dried fruits
Zinc (mg)	12	15	19	Component of numerous enzyme systems; possibly important in preventing congenital malformations	Liver, shellfish, meats, whole grains, milk
Iodine ( xg)	150	175	200	Increased maternal metabolic rate	Iodized salt, seafood, milk and milk products, commercial yeast breads, rolls, donuts
Magnesium (mg)	360/320	400/360	360/320	Involved in energy and protein metabolism, tissue growth, muscle action	Nuts, legumes, cocoa, meats, whole grains
FAT-SOLUBLE VITAMINS
A (RE)	800	800	1300	Essential for cell development, tooth bud formation, bone growth	Deep green leafy vegetables, dark yellow vegetables and fruits, chili peppers, liver, fortified margarine and butter
D (gμ)	5	5	5	Involved in absorption of calcium and phosphorus, improves mineralization	Fortified milk and margarine, egg yolk, butter, liver, seafood
E(mg)	8	10	12	Antioxidant (protects cell membranes from damage), especially important for preventing breakdown of RBCs	Vegetable oils, green leafy vegetables, whole grains, liver, nuts and seeds, cheese, fish
WATER-SOLUBLE VITAMINS
C (mg)	60	70	95	Tissue formation and integrity, formation of connective tissue, enhancement of iron absorption	Citrus fruits, strawberries, melons, broccoli, tomatoes, peppers, raw deep green leafy vegetables
Folic acid (gμ)	400	600	500	Prevention of neural tube defects, support increased maternal RBC formation	Fortified ready-to-eat cereals and other grains, green leafy vegetables, oranges, broccoli, asparagus, artichokes, liver
Thiamine (mg)	1.0/1.1	1.4	1.5	Involved in energy metabolism	Pork, beef, liver, whole or enriched grains, legumes
Riboflavin (mg)	1.0/1.1	1.4	1.6	Involved in energy and protein metabolism	Meat, liver, deep green vegetables, whole grains
Niacin (mg)	14	18	17	Involved in energy metabolism	Meat, fish, poultry, liver, whole or enriched grains, peanuts
Pyridoxine (B6) (mg)	1.2/1.3	1.9	2.0	Involved in protein metabolism	Meat, liver, deep green vegetables, whole grains
B12 ( xg)	2.4	2.6	2.8	Production of nucleic acids and proteins, especially important in formation of RBC and neural functioning	Milk and milk products, egg, meat, liver, fortified soy milk

 

Recommendations are the new dietary reference intakes (RDAor Al, see text) where available (Food and Nutrition Board, National Academy of Sciences, Institute of Medicine. [1998]. Recommended levels for individual intake, B vitamins, and choline. Washington, DC: National Academy Press; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. [1997]. Dietary reference intakes: Calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press). Where DRI are not yet available, the values are taken from Food and Nutrition Board (1989).

RBC, Red blood cells.

*When two values appear, separated by a diagonal slash, the first is for females <19 years and the second is for those 19 to 50 years old.

ENERGY NEEDS

Energy (kilocalories; abbreviated kcal) needs are met by carbohydrate, fat, and protein in the diet. No specific recommendations exist for the amount of carbohydrate and fat in the diet of the pregnant woman. However, intake of these nutrients should be adequate to support the recommended weight gain. Although protein can be used to supply energy, its primary role is to provide amino acids for the synthesis of new tissues (see discussion on protein later in this chapter). The RDA during the second and third trimesters of pregnancy is 300 kcal greater than prepregnancy needs; very underweight or active women may require more than 300 additional kcal to sustain the desired rate of weight gain.

 

Weight gain

The optimal weight gain during pregnancy is not known precisely. It is known, however, that the amount of weight gained by the mother during pregnancy has an important bearing on the course and outcome of pregnancy.

Adequate weight gain reduces the risk of delivering a small for gestational age (SGA) or preterm infant.

The desirable weight gain during pregnancy varies among individual women. Maternal and fetal risks in pregnancy are increased when the mother is either significantly underweight or overweight before pregnancy and when weight gain during pregnancy is either too low or too high. Women with inadequate weight gain have an increased risk of delivering an infant with intrauterine growth restriction (IUGR). Greater-than-expected weight gain during pregnancy may occur for many reasons, including multiple gestation, edema, pregnancy-induced hypertension, and overeating. When obesity is present (either preexisting or developed during pregnancy), there is an increased likelihood of macrosomia and fetopelvic disproportion, operative birth, birth trauma, and infant death. Obese women are more likely to have hypertension and diabetes, and their risk of giving birth to a child with a major congenital defect is double that of normal-weight women (Prentice & Goldberg, 1996). The cost of pregnancy in an obese woman has been estimated to be triple that of a normal-weight woman (Prentice & Goldberg, 1996).

The primary factor to consider in making a weight gain recommendation is the appropriateness of the prepregnancy weight for the woman’s height. A commonly used method of evaluating the appropriateness of weight for height is the body mass index (BMI), which is calculated by the following formula:

BMI = Weight/Height2

where the weight is in kilograms and height is in meters. Thus for a woman who weighed 51 kg before pregnancy and is 1.57 m tall:

BMI = 51/(1.57)2, or 20.7

BMI can be classified into the following categories: less than 19.8, underweight or low; 19.8 to 26.0, normal; 26.0 to 29.0, overweight or high; and greater than 29.0, obese.

For women with single fetuses, current recommendations are that women with a normal BMI should gain 11.5 to 16 kg during pregnancy, underweight women should gain 12.5 to 18 kg, overweight women should gain 7 to 11.5 kg, and obese women should gain at least 7 kg. Adolescents are encouraged to strive for weight gains at the upper end of the recommended range for their BMI because it appears that the fetus and the still-growing mother compete for nutrients. The risk of mechanical complications at birth is reduced if the weight gain of short adult women (i.e., less than 157 cm) is near the lower end of their recommended range. In twin gestations, gains of approximately 16 to 20 kg appear to be associated with the best outcomes (Ellings, Newman, & Bower, 1998).

 

PATTERN OF WEIGHT GAIN

Weight gain should take place throughout pregnancy. The risk of delivering an SGA infant is greater when the weight gain early in pregnancy has been poor. The likelihood of preterm birth is greater when the gains during the last half of pregnancy have been inadequate. These risks exist even when the total gain for the pregnancy is in the recommended range.

The optimal rate of weight gain depends on the stage of pregnancy. During the first and second trimesters, growth takes place primarily in maternal tissue; during the third trimester, growth occurs primarily in fetal tissues. During the first trimester there is an average total weight gain of only 1 to 2.5 kg. Thereafter the recommended weight gain increases to approximately 0.4 kg per week for a woman of normal weight (Fig. 2). The recommended weekly weight gain for overweight women during the second and third trimesters is 0.3 kg, and for underweight women it is 0.5 kg. The recommended caloric intake corresponds to this pattern of gain. For the first trimester there is no increment; during the second and third trimesters an additional 300 kcal/day over the prepregnant intake is recommended. The amount of food providing 300 kcal is not great. It can be provided by one additional serving from each of the following groups: milk, yogurt, or cheese (all skim milk products); fruits; vegetables; and bread, cereal, rice, or pasta.

 

Fig. 2 Prenatal weight gain chart for plotting weight gain of normal-weight women. Young adolescents, African-American women, and smokers should aim for the upper end of the recommended range; short women (less than 157 cm) should strive for gains at the lower end of the range.

 

The reasons for an inadequate weight gain (less than 1 kg per month for normal-weight women or less than 0.5 kg per month for obese women during the last two trimesters) or excessive weight gain (more than 3 kg per month) should be evaluated thoroughly. Possible reasons for deviations from the expected rate of weight gain include measurement or recording errors, differences in weight of clothing or time of day, and accumulation of fluids, as well as inadequate or excessive dietary intake. An exceptionally high gain is likely to be caused by an accumulation of fluids, and a gain of more than 3 kg in a month, especially after the twentieth week of gestation, often heralds the development of pregnancy-induced hypertension.

 

HAZARDS OF RESTRICTING ADEQUATE WEIGHT GAIN

An obsession with thinness and dieting permeates the North American culture. Slender, figure-conscious women may find it difficult to make the transition from guarding against weight gain before pregnancy to valuing weight gain during pregnancy. In counseling these women, the nurse can emphasize the positive effects of good nutrition, as well as the adverse effects of maternal malnutrition (manifested by poor weight gain) on infant growth and development. This counseling includes information on the components of weight gain during pregnancy (Fig. 3) and the amount of this weight that will be lost at birth. Early in a woman’s pregnancy, explaining ways to lose weight in the postpartum period helps relieve her concerns. Because lactation can help to reduce maternal energy stores gradually, this provides an opportunity to promote breastfeeding.

 

Fig. 3 Components of maternal weight gain at 40 weeks of gestation. (Modified from Worthington-Roberts, B., & Williams, S. [1997]. Nutrition in pregnancy and lactation [6th ed.]. Dubuque, IA: Brown & Benchmark.)

 

Pregnancy is not a time to diet. Even overweight or obese pregnant womeeed to gain at least enough weight to equal the weight of the products of conception (i.e., fetus, placenta, and amniotic fluid). If they limit their caloric intake to prevent weight gain, they may also excessively limit their intake of important nutrients. Moreover, dietary restriction results in catabolism of fat stores, which in turn augments the production of ketones. The longterm effects of mild ketonemia during pregnancy are not known, but ketonuria has been found to be correlated with the occurrence of preterm labor. It should be stressed to obese women, and to all pregnant women, that the quality of the weight gain is important, with emphasis on the consumption of nutrient-dense foods and the avoidance of empty-calorie foods.

Weight gain is important, but pregnancy is not an excuse for uncontrolled dietary indulgence. Excessive weight gained during pregnancy may be difficult to lose after pregnancy, thus contributing to chronic overweight or obesity, an etiologic factor in a host of chronic diseases, including hypertension, diabetes mellitus, and arteriosclerotic heart disease. The woman who gains 18 kg or more during pregnancy is especially at risk.

 

Protein

Protein, with its essential constituent nitrogen, is the nutritional element basic to growth. Adequate protein is essential to meet increasing demands in pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus and its supporting structures, mammary glands, and placenta; an increase in maternal circulating blood volume and the subsequent demand for increased amounts of plasma protein to maintain colloidal osmotic pressure; and the formation of amniotic fluid.

Milk, meat, eggs, and cheese are complete protein foods with a high biologic value. Legumes (dried beans and peas), whole grains, and nuts are also valuable sources of protein. In addition, these protein-rich foods are a source of other nutrients such as calcium, iron, and B vitamins; plant sources of protein often provide needed dietary fiber. The recommended daily food plan (Table 2) is a guide to the amounts of these foods that would supply the quantities of proteieeded. The recommendations provide for only a modest increase in protein intake over the prepregnant levels in adult women. Protein intake in many people in the United States is relatively high, so many women may not need to increase their protein intake at all during pregnancy. Three servings of milk, yogurt, or cheese (four for adolescents) and 5 to 6 ounces (140 to 168 g) (two servings) of meat, poultry, or fish supply the recommended protein for the pregnant woman. Additional protein is provided by vegetables and breads, cereals, rice, and pasta. Pregnant adolescents, women from impoverished backgrounds, and women adhering to unusual diets such as a macrobiotic (highly restricted vegetarian) diet are those whose protein intake is most likely to be inadequate. The use of high-protein supplements is not recommended because they have been associated with an increased incidence of preterm births.

 

Table 2 Daily Food Guide for Pregnancy and Lactation

 

Fluids

Water is the main substance of cells, blood, lymph, amniotic fluid, and other vital body fluids and is essential during the exchange of nutrients and waste products across cell membranes. It also aids in maintaining body temperature. A good fluid intake promotes good bowel function, which is sometimes a problem during pregnancy. Dehydration may increase the risk of cramping/contractions and preterm labor. The recommended daily intake is 6 to 8 glasses (1500 to 2000 ml) of fluid. Water, milk, and juices are good sources of fluids.

Women who consume more than 300 mg of caffeine daily (equivalent to 500 to 750 ml of coffee) are at increased risk of miscarriage and of delivering infants with IUGR. Caffeine’s ill effects have been proposed to result from vasoconstriction of the blood vessels supplying the uterus or interference with cell division in the developing fetus (Hinds et al., 1996). Consequently, caffeine-containing products, including caffeinated coffee, tea, soft drinks, and cocoa beverages, should be avoided or consumed only in limited quantities.

Aspartame (e.g., Nutrasweet, Equal) and acesulfame K (e.g., Sweet One), artificial sweeteners commonly used in low- or no-calorie beverages, have not been found to have adverse effects on the normal mother or fetus, but aspartame use should be avoided by pregnant women who are homozygous for phenylketonuria (PKU).

 

Minerals and Vitamins

In general, the nutrient needs of pregnant women, except perhaps the need for iron, can be met through dietary sources. Counseling about the need for a varied diet rich in vitamins and minerals should be a part of every pregnant woman’s early prenatal care and should be reinforced throughout pregnancy. However, supplements of certaiutrients (listed in the following discussion) are recommended whenever the woman’s diet is very poor or whenever significant nutritional risk factors are present. Nutritional risk factors in pregnancy are listed in Box 1.

 

BOX 1 Indicators of Nutritional Risk in Pregnancy Adolescence Frequent pregnancies: three within 2 years Poor fetal outcome in a previous pregnancy Poverty Poor diet habits with resistance to change Use of tobacco, alcohol, or drugs Weight at conception under or over normal weight Problems with weight gain Any weight loss Weight gain of less than 1 kg/mo after the first trimester Weight gain of more than 1 kg/wk after the first trimester Multifetal pregnancy Low hemoglobin or hematocrit values (or both)

 

Iron

Iron is needed both to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell (RBC) mass. Beginning in the latter part of the first trimester the blood volume of the mother increases steadily, peaking at approximately 1500 ml more than in the nonpregnant state. In twin gestations, the increase is at least 500 ml greater than in pregnancies with single fetuses. Plasma volume increases more than RBC mass. The relative excess of plasma causes a modest decrease in the hemoglobin concentration and hematocrit, known as physiologic anemia of pregnancy. This is a normal adaptation during pregnancy.

However, poor iron intake and absorption, which can result in iron deficiency anemia, is relatively common among women in the childbearing years. It affects nearly one fifth of the pregnant women in industrialized countries. The maternal mortality rate is increased among anemic women, who are poorly prepared to tolerate hemorrhage at the time of birth. In addition, anemic women may have a greater likelihood of cardiac failure during labor, postpartum infections, and poor wound healing. The fetus is also affected by maternal anemia. The risk of preterm birth is greater in anemic women, and fetal iron stores may also be reduced by maternal anemia (Allen, 2000). Anemia is more common among adolescents and African-American women than among adult Caucasian women.

Evidence supports the recommendation that all pregnant women receive a daily iron supplement (Allen, 2000). (Iron supplements may be poorly tolerated during the nausea that is prevalent in the first trimester.) If iron deficiency anemia (as manifested by low levels of hematocrit or hemoglobin and serum ferritin) is present, higher dosages are required. Certain foods taken with an iron supplement can promote or inhibit absorption of iron. Even when a woman is taking an iron supplement, she should include good food sources of iron in her daily diet (see Table 1).

 

Calcium

There is no increase in the DRI of calcium during pregnancy and lactation, in comparison with the recommendation for the nonpregnant woman (see Table 1). The DRI (1000 mg daily for women 19 and older and 1300 mg for those younger than 19) appears to provide sufficient calcium for fetal bone and tooth development to proceed while maintaining maternal bone mass.

Milk and yogurt are especially rich sources of calcium, providing approximately 300 mg per cup (240 ml). Nevertheless, many women do not consume these foods or do not consume adequate amounts to provide the recommended intakes of calcium. One problem that can interfere with milk consumption is lactose intolerance, the inability to digest milk sugar (lactose) caused by the absence of the lactase enzyme in the small intestine. Lactose intolerance is relatively common in adults, particularly African-Americans, Asians, Native Americans, and Eskimos. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people. Yogurt, sweet acidophilus milk, buttermilk, cheese, chocolate milk, and cocoa may be tolerated even when fresh fluid milk is not. Commercial products that contain the lactase enzyme (e.g., Lactaid) are available in pharmacies and many supermarkets. The lactase in these products hydrolyzes, or digests, the lactose in milk, making it possible for lactose-intolerant people to drink milk.

In some cultures, adults rarely drink milk. For example, Puerto Ricans and other Hispanic people may use it only as an additive in coffee. Pregnant women from these cultures may need to consume nondairy sources of calcium. Vegetarian diets may also be deficient in calcium (Box 2). If calcium intake appears low and the woman does not change her dietary habits despite counseling, a daily supplement containing 600 mg of elemental calcium may be needed. Calcium supplements may also be recommended when a pregnant woman experiences leg cramps caused by an imbalance in the calcium/phosphorus ratio.

 

BOX 2 Calcium Sources for Women Who Do Not Drink Milk Each of the following provides approximately the same amount of calcium as 1 cup of milk: FISH 3 oz can of sardines 4V2 oz can of salmon (if bones are eaten) BEANS AND LEGUMES 3 cups of cooked dried beans 2VS cups of retried beans 2 cups of baked beans with molasses 1 cup of tofu (calcium is added in processing) GREENS 1 cup of collards 1V2 cups of kale or turnip greens BAKED PRODUCTS 3 pieces of cornbread 3 English muffins 4 slices of French toast 2 (7 inch diameter) waffles FRUITS 11 dried figs 1V8 cups of orange juice with calcium added SAUCES 3 oz of pesto sauce 5 oz of cheese sauce

 

Sodium

During pregnancy the need for sodium increases slightly, primarily because the body water is expanding (e.g., the expanding blood volume). Sodium is essential for maintaining body water balance. Grain, milk, and meat products, which are good sources of nutrients needed during pregnancy, are significant sources of sodium.

In the past, dietary sodium was routinely restricted i effort to control the peripheral edema that commonly occurs during pregnancy. However, it is now recognized that moderate peripheral edema is normal in pregnancy, occurring as a response to the fluid-retaining effects of elevated levels of estrogen. An excessive emphasis on sodium restriction may make it difficult for pregnant women to achieve an adequate diet. In addition, restriction of sodium intake may stress the adrenal glands and the kidney as they attempt to retain adequate sodium. In general, sodium restriction is necessary only if the woman has a medical condition such as renal or liver failure or hypertension.

Excessive intake of sodium is discouraged during pregnancy just as it is ionpregnant women, because it may contribute to abnormal fluid retention and edema. Table salt (sodium chloride) is the richest source of sodium. Most canned foods contain added salt unless the label pecifically states otherwise. Large amounts of sodium are also found in many processed foods, including meats (e.g., smoked or cured meats, cold cuts, corned beef), baked goods, mixes for casseroles or grain products, soups, and condiments. Products low iutritive value and excessively high in sodium include pretzels, potato and other chips, pickles, ketchup, prepared mustard, steak and Worcestershire sauces, some soft drinks, and bouillon. A moderate sodium intake can usually be achieved by salting food lightly in cooking, adding no additional salt at the table, and avoiding low-nutrient/high-sodium foods.

 

Zinc

Zinc is a constituent of numerous enzymes involved in major metabolic pathways. Zinc deficiency is associated with malformations of the central nervous system in infants. When large amounts of iron and folic acid are consumed, the absorption of zinc is inhibited and serum zinc levels are reduced as a result. Because iron and folic acid supplements are commonly prescribed during pregnancy, pregnant women should be encouraged to consume good sources of zinc daily (see Table 10-1). Women with anemia who receive high-dose iron supplements also need supplements of zinc (King, 2000).

 

Fluoride

The effect of prenatal fluoride supplementation on tooth development in the infant is not fully known. However, it appears that prenatal fluoride supplementation has little effect on the incidence and prevalence of tooth decay (Leverett et al., 1997). No increase in fluoride intake over the nonpregnant DRI is currently recommended during pregnancy (Standing Committee, 1997).

 

Fat-soluble vitamins

Fat-soluble vitamins (i.e., vitamins A, D, E, and K) are stored in the body tissues. With chronic overdoses, these vitamins can reach toxic levels. Because of the high potential for toxicity, pregnant women are advised to take fatsoluble vitamin supplements only as prescribed. Vitamins A and D deserve special mention.

Adequate intake of vitamin A is needed so that sufficient amounts can be stored in the fetus. However, dietary sources can readily supply sufficient amounts. Congenital malformations have occurred in infants of mothers who took excessive amounts of vitamin A during pregnancy, and thus supplements are not recommended for pregnant women. Vitamin A analogs such as isotretinoin (Accutane), which are prescribed for the treatment of cystic acne, are a special concern. Isotretinoin use during early pregnancy has been associated with an increased incidence of heart malformations, facial abnormalities, cleft palate, hydrocephalus, and deafness and blindness in the infant, as well as an increased risk of miscarriage. Topical agents such as tretinoin (Retin-A) do not appear to enter the circulation in any substantial amounts, but their safety in pregnancy has not been confirmed.

Vitamin D plays an important role in absorption and metabolism of calcium. The main food sources of this vitamin are enriched or fortified foods such as milk and ready-to-eat cereals. Vitamin D is also produced in the skin by the action of ultraviolet light (in sunlight). Severe deficiency may cause neonatal hypocalcemia and tetany, as well as hypoplasia of the tooth enamel. Women with lactose intolerance and those who do not include milk in their diet for any reason are at risk for vitamin D deficiency. Other risk factors are dark skin, habitual use of clothing that covers most of the skin, and living iorthern latitudes where sunlight exposure is limited, especially during the winter.

 

Water-soluble vitamins

Body stores of water-soluble vitamins are much smaller than those of fat-soluble vitamins; the water-soluble vitamins, in contrast to fat-soluble vitamins, are readily excreted in the urine. Therefore good sources of water-soluble vitamins must be consumed frequently, and toxicity with overdose is less likely than with fat-soluble vitamins.

Because of the increase in RBC production during pregnancy, as well as the nutritional requirements of the rapidly growing cells in the fetus and placenta, pregnant women should consume approximately 50% more folic acid thaonpregnant women, or approximately 600 /jug daily. This increased need for folic acid continues during lactation (Bailey & Gregory, 1999). In the United States, all enriched grain products (this includes most white breads, flour, and pasta) must contain folic acid at a level of 1.4 mg per kilogram of flour. This level of fortification supplies approximately 0.1 mg of folic acid daily in the average American diet (USDHHS, FDA, 1996). All women of childbearing potential need careful counseling about including good sources of folic acid in their diet (Tinkle & Sterling, 1997).

Pyridoxine, or vitamin B6, is involved in protein metabolism. Although levels of a pyridoxine-containing enzyme have been reported to be low in women with pregnancyinduced hypertension, there is no evidence that supplementation prevents or corrects the condition. No supplement is recommended routinely, but women with poor diets and those at nutritional risk (see Box 1) may need a supplement. Supplementation is related to a lowered incidence of dental decay in pregnant women (Mahomed & Gulmezoglu, 2000).

Vitamin C, or ascorbic acid, plays an important role in tissue formation and enhances the absorption of iron. The vitamin C needs of most women are readily met by a diet that includes at least five servings per day of fruits and vegetables (Levine et al., 1999) (see Table 1), but women who smoke need more. For women at nutritional risk, a supplement is recommended. However, if the mother takes excessive doses of this vitamin during pregnancy, a vitamin C deficiency may develop in the infant after birth.

 

Nutrient supplements

Food can and should be the normal vehicle to meet the additional needs imposed by pregnancy (excepting iron, for which a supplemental dose is recommended). However, some women chronically consume diets that are deficient in necessary nutrients and, for whatever reason, may be unable to change this intake. For these women a supplement should be considered. It is important that the pregnant woman understand that the use of a vitamin/mineral supplement does not lessen the need to consume a nutritious, well-balanced diet.

 

OTHER NUTRITIONAL ISSUES DURING

PREGNANCY

Pica and food cravings

Pica is the practice of consuming nonfood substances (e.g., clay, dirt, laundry starch) or excessive amounts of foodstuffs low in nutritional value (e.g., cornstarch, ice, baking powder, soda). Pica is often influenced by the woman’s cultural background. In the United States it appears to be most common among African-American women, women from rural areas, and women with a family history of pica. Regular and heavy consumption of low-nutrient products may cause more nutritious foods to be displaced from the diet, and the items consumed may interfere with the absorption of nutrients, especially minerals. Women with pica have lower hemoglobin levels than those without pica (Rainville, 1998). The possibility of pica must be considered when pregnant women are found to be anemic, and the nurse should provide counseling about the health risks associated with pica. The existence of pica, as well as details of the type and amounts of products ingested, is likely to be discovered only by the sensitive interviewer who has developed a relationship of trust with the woman. It has been proposed that pica and food cravings (e.g., the urge to consume ice cream, pickles, pizza) during pregnancy are caused by an innate drive to consume nutrients missing from the diet. However, research has not supported this hypothesis.

 

Adolescent pregnancy

Many adolescent females have diets that fall below the recommended intakes of key nutrients, including energy, calcium, and iron. Teens have lower BMIs than adults and are at risk for having babies of lower birth weight than adult women (Buschman, Foster, & Vickers, 2001).

Pregnant adolescents and their infants are at increased risk of complications during pregnancy and parturition. Growth of the pelvis is delayed in comparison to growth in stature, and this helps explain why cephalopelvic disproportion and other mechanical problems associated with labor are common among young adolescents. Competition between the growing adolescent and the fetus for nutrients may also contribute to some of the poor outcomes apparent in teen pregnancies. Pregnant adolescents are encouraged to choose a weight gain goal at the upper end of the range for their BMI (see Research box).

 

RESEARCH Weight Gain and Birth Weight in the Pregnant Young Teen The weight of newborns is correlated with immediate survival and with long-term health. Pregnancy in adolescence is especially vulnerable to a low-birthweight outcome, possibly because the adolescent starts pregnancy with a lower body mass index (BMI), has poor nutrition, or is still growing herself. Low birth weight for gestation indicates pathology of the fetus, mother, or placenta. Birth weight of the baby is dependent on weight gain of the mother during pregnancy. Girls 16 years of age and older share the same weight gain patterns and pregnancy outcomes as adult women. Younger teens, however, do not fit this pattern. Studying a region of Scotland with a high rate of teen pregnancy, researchers retrospectively compared 104 pregnant adolescents, ages 13 to 15 years, with a control group of 150 pregnant adults, ages 25 to 30 years. The researchers calculated the “prepregnancy BMI” based on weight and height at first visit up to 16 weeks of gestation. The “end-of-pregnancy BMI” calculation came from the original height and the recorded weight at 36 or more weeks of gestation. Analysis of the data confirmed that the adolescents started and ended pregnancy with lower BMIs than the adults. For both groups, a higher end-of-pregnancy BMI correlated to higher birth weights. Adolescents gained as much weight in proportion to body size as adult women, yet still delivered lower-birth-weight babies. It was noteworthy that 30% of the adolescents smoked, compared with 18% of adults, which also may have affected birth weight. IMPLICATIONS FOR PRACTICE Nurses who encounter young pregnant teens need to be aware of their special nutritional needs. Involving the nutritionist and the family members who prepare the meals may assist the teen in eating the right kinds of food for a healthy baby outcome. Referrals to special “Teen OB” clinics and peer support groups may provide conducive environments for teens to be educated about nutrition, smoking cessation, and the importance of preventing low-birth-weight babies. Source: Buschman, N., Foster, G., & Vickers, P. (2001). Adolescent girls and their babies: Achieving optimal birthweight. Gestational weight gain and pregnancy outcome in terms of gestation at delivery and infant birth weight: A comparision between adolescents under 16 and adult women. Child Care Health Dev, 27(1) 163-171.

 

NUTRIENT NEEDS DURING LACTATION

Nutritional needs during lactation are similar in many ways to those during pregnancy (see Table 1). Needs for energy (calories), protein, calcium, iodine, zinc, the B vitamins (thiamine, riboflavin, niacin, pyridoxine, and vitamin B12), and vitamin C remain elevated over nonpregnant needs. The recommendations for some of these (e.g., vitamin C, zinc, protein) are slightly to moderately higher than during pregnancy. This allowance covers the amount of the nutrient released in the milk, as well as the needs of the mother for tissue maintenance. In the case of iron and folk acid, the recommendation during lactation is lower than during pregnancy. Both of these nutrients are essential for RBC formation, and thus for maintaining the increase in the blood volume that occurs during pregnancy. With the decrease in maternal blood volume to nonpregnant levels after birth, maternal iron and folic acid needs also fall. Many lactating women experience a delay in the return of menses, and this also conserves blood cells and reduces iron and folic acid needs. It is especially important that the calcium intake be adequate; if it is not and the women does not respond to diet counseling, a supplement of 600 mg of calcium per day may be needed.

The recommended energy intake is an increase of 500 kcal more than the woman’s nonpregnant intake. Lactating women should consume at least 1800 kcal/day; it is difficult to obtain adequate nutrients for maintenance of lactation at levels below that. Because of deposition of energy stores, the woman who has gained the optimal amount of weight during pregnancy is heavier after birth than at the beginning of pregnancy. As a result of the caloric demands of lactation, however, the lactating mother usually experiences a gradual but steady weight loss. Most women experience a rapid loss of several pounds during the first month postpartum whether or not they breastfeed. After the first month the average loss during lactation is 0.5 to 1.0 kg per month, and a woman who is overweight may be able to lose up to 2 kg without decreasing her milk supply.

Fluid intake must be adequate to maintain milk production, but the mother’s level of thirst is the best guide to the right amount. There is no need to consume fluids in excess of the amount needed to satisfy thirst.

CARE MANAGEMENT

During pregnancy, nutrition plays a key role in achieving an optimum outcome for the mother and her unborn baby. Motivation to learn about nutrition is usually higher during pregnancy as parents strive to “do what’s right for the baby.” Optimal nutrition cannot eliminate all problems that may arise in pregnancy, but it does establish a good foundation for supporting the needs of the mother and her unborn baby.

 

Assessment and Nursing Diagnoses

Assessment is based on a diet history (a description of the woman’s usual food and beverage intake and factors affecting her nutritional status, such as medications being taken and adequacy of income to allow her to purchase the necessary foods) obtained from an interview and re view of the woman’s health records, physical examination, and laboratory results. Ideally, a nutritional assessment is performed before conception so that any recommended changes in diet, lifestyle, and weight can be undertaken before the woman becomes pregnant.

 

Diet history

Obstetric and gynecologic effects on nutrition. Nutritional reserves may be depleted in the multiparous woman or one who has had frequent pregnancies (especially three pregnancies within 2 years). A history of preterm birth or the birth of an LBW or SGA infant may indicate inadequate dietary intake. Pregnancy-induced hypertension may also be a factor in poor maternal nutrition. Birth of an infant who is large for gestational age may indicate maternal diabetes mellitus. Previous contraceptive methods also may affect reproductive health. Increased menstrual blood loss often occurs during the first 3 to 6 months after placement of an intrauterine contraceptive device. Consequently, the user may have low iron stores or even iron deficiency anemia. Oral contraceptive agents, on the other hand, are associated with decreased menstrual losses and increased iron stores; however, oral contraceptives may interfere with folic acid metabolism.

Medical history. Chronic maternal illnesses, such as diabetes mellitus, renal disease, liver disease, or cystic fibrosis, or other malabsorptive disorders, seizure disorders and the use of anticonvulsant agents, hypertension, and PKU may affect nutritional status and dietary needs. In women with illnesses that have resulted iutritional deficits or that require dietary treatment (e.g., diabetes mellitus, PKU), it is extremely important for nutritional care to be started and for the condition to be optimally controlled before conception. A registered dietitian can provide in-depth counseling for the woman who requires a therapeutic diet during pregnancy and lactation.

Usual maternal diet. The woman’s usual food and beverage intake, adequacy of income and other resources to meet her nutritional needs, any dietary modifications, food allergies and intolerances, and all medications and nutrition supplements being taken, as well as pica and cultural dietary requirements, should be ascertained. In addition, the presence and severity of nutrition-related discomforts of pregnancy, such as morning sickness, constipation, and pyrosis (heartburn), should be determined. The nurse should be alert to any evidence of eating disorders such as anorexia nervosa, bulimia, or frequent and rigorous dieting before or during pregnancy.

The impact of food allergies and intolerances on nutritional status ranges from very important to almost nil. Lactose intolerance is of special concern in pregnant and lactating women because no other food group equals milk and milk products in terms of calcium content. If a woman suffers from lactose intolerance, the interviewer should explore her intake of other calcium sources (see Box 2).

The assessment must include an evaluation of the woman’s financial status and her knowledge of sound dietary practices. The quality of the diet increases with increasing socioeconomic status and educational level. Poor women may not have access to adequate refrigeration and cooking facilities and may find it difficult to obtain adequate nutritious food.

Herbal supplements. Specific questions about the use of botanicals (e.g., herbs and other “natural” remedies) should be included in the assessment (Hatcher, 2001). Whether the woman uses herbs as part of her culture or tradition should be ascertained; this will assist the nurse to determine the clinical significance of the use of herbs. The following questions can be included in the assessment (Hatcher, 2001):

• Have you used or considered using herbal or vitamin supplements?

• Have you recently had a symptom that over-the-counteror prescription medications did not relieve? Have you tried to find relief using an herbal remedy?

• Have you ever used the herbs feverfew, ginseng, or garlic? (These herbs prolong clotting times.)

• Do you combine herbal remedies with over-the-counter or prescription medications?

Box 3 provides a simple tool for obtaining diet history information. When potential problems are identified, they should be followed up with a careful interview. Women should be cautioned to avoid the use of herbs during pregnancy and lactation.

 

Box 3 Food Intake Questionnaire

 

 

Physical examination

Anthropometric measurements (body measurements, such as height and weight) provide both short- and longterm information on a woman’s nutritional status and are thus essential to the assessment. At a minimum, the woman’s height and weight must be determined at the time of her first prenatal visit and her weight should be measured at every subsequent visit (see earlier discussion of BMI).

A careful physical examination can reveal objective signs of malnutrition (Table 3). It is important to note, however, that some of these signs are nonspecific and that the physiologic changes of pregnancy may complicate the interpretation of physical findings. For example, lower extremity edema often occurs in calorie and protein deficiency, but it may also be a normal finding in the third trimester of pregnancy. Interpretation of physical findings is made easier by a thorough health history and by laboratory testing, if indicated.

 

 

 

Laboratory testing

The only nutrition-related laboratory testing needed by most pregnant women is a hematocrit or hemoglobin measurement to screen for the presence of anemia. Because of the physiologic anemia of pregnancy, the reference values for hemoglobin and hematocrit must be adjusted during pregnancy. The lower limit of the normal range for hemoglobin during pregnancy is 11 g/dl in the first and third trimesters and 10.5 g/dl in the second trimester (compared with 12 g/dl in the nonpregnant state). The lower limit of the normal range for hematocrit is 33% during the first and third trimesters and 32% in the second trimester (compared with 36% in the nonpregnant state). Cutoff values for anemia are higher in women who smoke or live at high altitudes, because the decreased oxygen-carrying capacity of their RBCs causes them to produce more RBCs than other women.

A woman’s history or physical findings may indicate the need for additional testing, such as a complete blood cell count with a differential to identify megaloblastic or macrocytic anemia and measurement of levels of specific vitamins or minerals believed to be lacking in the diet.

The assessment gives a basis for making appropriate nursing diagnoses, such as the following.

• Imbalanced nutrition: less than body requirements related to

-inadequate information about nutritional needs and weight gain during pregnancy

-misperceptions regarding normal body changes during pregnancy and inappropriate fear of becoming fat

-inadequate income or skills in meal planning and preparation

• Imbalanced nutrition: more than body requirements related to

-excessive intake of energy (calories) or decrease in activity during pregnancy

-use of unnecessary dietary supplements

• Constipation related to

-decrease in gastrointestinal motility because of elevated progesterone levels

-compression of intestines by the enlarging uterus

-oral iron supplementation

 

EXPECTED OUTCOMES OF CARE

The nurse, dietitian, physician, and nurse-midwife collaborate with the woman in helping her achieve nutrition-related expected outcomes. Some commoutrition-related outcomes are that the woman will take the following actions:

• Achieve an appropriate weight gain during pregnancy. An appropriate goal for weight gain takes into account such factors as prepregnancy weight, whether she is overweight/obese or underweight, and whether the pregnancy is single or multifetal.

• Consume adequate nutrients from the diet and supplements to meet estimated needs.

• Cope successfully with nutrition-related discomforts associated with pregnancy, such as morning sickness, pyrosis (heartburn), and constipation.

 

PLAN OF CARE AND INTERVENTIONS

Nutritional care and teaching generally involve (1) acquainting the woman with nutritional needs during pregnancy and, if necessary, the characteristics of an adequate diet; (2) helping her individualize her diet so that she achieves an adequate intake while satisfying her personal, cultural, financial, and health needs; (3) acquainting her with strategies for coping with the nutrition-related discomforts of pregnancy; (4) helping the woman use nutrition supplements appropriately; and (5) consulting with and making referrals to other professionals or services as indicated. Two programs that provide nutrition services are the food stamp program and the Special Supplemental Program for Women, Infants, and Children (WIC). These programs provide vouchers for selected foods to pregnant and lactating women, as well as infants and children at nutritional risk. WIC foods include items such as eggs, cheese, milk, juice, and fortified cereals; these foods are chosen because they provide iron, protein, vitamin C, and other vitamins.

Adequate dietary intake

Diet teaching can take place in a one-on-one interview or in a group setting. In either case it should emphasize the importance of choosing a varied diet composed of readily available foods, rather than specialized diet supplements. Good nutrition practices and avoidance of poor practices (e.g., smoking, alcohol or drug use) are essential content for prenatal classes designed for women in early pregnancy.

The food guide pyramid (Fig. 4) can be used as a guide to daily food choices during pregnancy and lactation, just as it is during other stages of the life cycle. The importance of consuming adequate amounts from the milk, yogurt, and cheese group must be emphasized, especially for adolescents and women younger than 25 years of age, who are still actively adding calcium to their skeletons; adolescents need at least 1 L of milk or the equivalent daily.

 

 

Fig. 4 Food guide pyramid, a guide to daily food choices. (Courtesy U.S. Department of Agriculture, Washington, DC.)

 

Pregnancy. The pregnant woman must understand what adequate weight gain during pregnancy means, must recognize the reasons for its importance, and must be able to evaluate her own gain in relation to the desirable pattern. Many women, particularly those who have worked hard to control their weight before pregnancy, may find it difficult to understand why the weight gain goal is so high when a newborn infant is so small. The nurse can explain that maternal weight gain consists of increments in the weight of many tissues, not just the growing fetus.

On the other hand, dietary overindulgence, which may result in excessive fat stores that persist after giving birth, should be discouraged. Nevertheless, it is best not to focus unduly on weight gain; this can result in feelings of stress and guilt in the woman who does not follow the preferred pattern of gain.

Postpartum. The need for a varied diet with portions of food from all food groups continues throughout lactation. As mentioned previously, the lactating woman should be advised to consume at least 1800 kcal daily, and she should receive counseling if her diet appears to be inadequate in any nutrients. Special attention should be given to her intake of zinc, vitamin B6, and folic acid because the recommendations for these remain higher than those for nonpregnant women (see Table 1). Sufficient calcium is needed to allow for both milk formation and maintenance of maternal bone mass. It may be difficult for lactating women to consume enough of these nutrients without careful diet planning.

The woman who does not breastfeed loses weight gradually if she consumes a balanced diet that provides slightly less than her daily energy expenditure. Lactating and nonlactating women should know that fat is the most concentrated source of calories in the diet (9 kcal/g versus 4 kcal/g in carbohydrates and proteins), and fat calories are more efficiently converted into fat stores than are calories from carbohydrate or protein. Therefore the first step in weight reduction (or controlling excessive weight gain) is to evaluate sourse of fat in the diet and explore with the patient ways of reducing them. Even foods such as vegetables that are naturally low in fat can become high in fat when fried or sauteed, served with excessive amounts of salad dressing, consumed with high-fat dips or sauces, or seasoned with butter or bacon drippings. A reasonable weight loss goal for nonlactating women is 0.5 to 1.0 kg/wk; a loss of 1.0 kg/mo is recommended for most lactating women who need to lose weight.

Daily food guide and menu planning. The daily food plan (see Table 2 and Fig. 10-4) can be used as a guide for educating women about nutritional needs during pregnancy and lactation. This food plan is general enough to be used by women from a variety of cultures, including those following a vegetarian diet. One of the more helpful teaching strategies is to assist the patient to plan daily menus that follow the food plan and are affordable, have realistic preparation times, and are compatible with personal preferences and cultural practices. Information regarding cultural food patterns is provided later in this chapter.

Therapeutic diets. During pregnancy and lactation, the food plan for women with special therapeutic diets may need to be modified. The registered dietitian can instruct these women about their diets and assist them in meal planning. However, the nurse should understand the basic principles of the diet and be able to reinforce the diet teaching.

The nurse should be especially aware of the dietary modifications necessary for women with diabetes mellitus (either gestational or preexisting) because this disease is relatively common and because fetal deformity and death occur more often in pregnancies complicated by hyperglycemia or hypoglycemia. Every effort should be made to maintain blood glucose levels in the normal range throughout pregnancy. The food plan of the woman with diabetes usually includes four to six meals and snacks daily, with the daily carbohydrate intake distributed fairly evenly among those meals and snacks. The complex carbohydrates (i.e., fibers and starches) should be well represented in the diet of the woman with diabetes. See Chapter 22 for a discussion of the woman with diabetes.

 

Iron supplementation

As mentioned earlier, the nutritional supplement most commonly needed during pregnancy is iron. However, a variety of dietary factors can affect the completeness of absorption of an iron supplement. The following points should be addressed in patient education:

• Bran, milk, egg yolks, coffee, tea, or oxalate-containing vegetables such as spinach and Swiss chard consumed at the same time as iron will inhibit iron absorption.

• Iron absorption is promoted by a diet rich in vitamin C (e.g., citrus fruits or melons) or “heme iron” found in red meats, fish, and poultry.

• Iron supplements are best absorbed on an empty stomach; thus they can be taken between meals with beverages other than milk, tea, or coffee.

• Some women have gastrointestinal discomfort when they take the supplement on an empty stomach; therefore a good time for them to take the supplement is just before bedtime.

• Constipation is common with iron supplementation.

• Iron supplements should be kept away from any children in the household because their ingestion could result in acute iron poisoning and even death.

 

Coping with nutrition-related discomforts of pregnancy

The most commoutrition-related discomforts of pregnancy are nausea and vomiting or “morning sickness,” constipation, and pyrosis.

Nausea and vomiting. Nausea and vomiting are most common during the first trimester. Usually, nausea and vomiting cause only mild to moderate problems nutritionally, although they may cause substantial discomfort. Antiemetic medications, vitamin B6, and P6 acupressure may be effective in reducing the severity of nausea (Jewell & Young, 2000). The pregnant woman may find the following suggestions helpful in alleviating the problem:

• Eat dry, starchy foods such as dry toast, Melba toast, or crackers on awakening in the morning and at other times wheausea occurs.

• Avoid consuming excessive amounts of fluids early in the day or wheauseated (but compensate by drinking fluids at other times).

• Eat small amounts frequently (every 2 to 3 hours) and avoid large meals, which distend the stomach.

• Avoid skipping meals and thus becoming extremely hungry, which may worseausea. Have a snack such as cereal with milk, a small sandwich, or yogurt before bedtime.

• Avoid sudden movements. Arise from bed slowly.

• Decrease intake of fried and other fatty foods. Starches (e.g., pastas, rice, breads) and low-fat protein foods (e.g., skinless broiled or baked poultry, cooked dry beans or peas, lean meats, broiled or canned fish) are good choices.

• Some women find that tart foods or drinks (e.g., lemonade) or salty foods (e.g., potato chips) are tolerated during periods of nausea.

• Herbal teas such as those made with raspberry leaf or peppermint may decrease nausea.

• Fresh air may help relieve nausea. Keep the environment well ventilated (e.g., open a window), go for a walk outside, or decrease cooking odors by using an exhaust fan.

• During periods of nausea, eat foods served at cool temperature and foods that give off little aroma.

• Avoid brushing teeth immediately after eating.

Hyperemesis gravidarum (i.e., severe and persistent vomiting causing weight loss, dehydration, and electrolyte abnormalities) occurs in up to 1% of pregnant women. 4f k) There is some evidence that ginger root may be effective in reducing nausea (Jewell & Young, 2000). Intravenous fluid and electrolyte replacement is usually necessary for women who lose 5% of their body weight. This is often followed by improved tolerance of oral intake; therapy then consists of frequently consuming small amounts of low-fat foods. Tube feedings may be used to supplement oral intake, with the volume of the tube feeding gradually being decreased as oral intake improves. In some instances, total parenteral nutrition (balanced intravenous feedings of amino acids, carbohydrate, lipid, vitamins, and minerals) is used to nourish women with hyperemesis gravidarum when their nutritional status is severely impaired.

Constipation. Improved bowel function generally results when the intake of fiber (e.g., wheat bran and wholewheat products, popcorn, raw or lightly steamed vegetables) in the diet is increased because fiber helps retain water within the stool, creating a bulky stool that stimulates intestinal peristalsis. The recommendation for adults for fiber is 25 to 30 g/day. An adequate fluid intake (at least 50 ml/kg/day) helps hydrate the fiber and increase the bulk of the stool. Making a habit of regular exercise that uses large muscle groups (walking, swimming, cycling) also helps stimulate bowel motility.

Pyrosis. Pyrosis, or heartburn, is usually caused by reflux of gastric contents into the esophagus. This condition can be minimized by eating small, frequent meals rather than two or three larger meals daily. Because fluids increase the distention of the stomach, they should not be consumed with foods. The womaeeds to be sure to drink adequate amounts between meals. Avoiding spicy foods may help alleviate the problem. Lying down immediately after eating and wearing clothing that is tight across the abdomen can contribute to the problem of reflux.

 

Cultural influences

Consideration of a woman’s cultural food preferences enhances communication and provides a greater opportunity for following the agreed-on pattern of intake. Women in most cultures are encouraged to eat a diet typical for them. The nurse needs to be aware of what constitutes a typical diet for each cultural or ethnic group with whom she works. However, several variations may occur within one cultural group. Thus careful exploration of individual preferences is needed. Although ethnic and cultural food beliefs may seem, at first glance, to conflict with the dietary instruction provided by physicians, nurses, and dietitians, it is often possible for the empathic health care provider to identify cultural beliefs that are congruent with the modern understanding of pregnancy and fetal development. Many cultural food practices have some merit or the culture would not have survived. Food cravings during pregnancy are considered normal by many cultures, but the kinds of cravings often are culturally specific. In most cultures women crave acceptable foods, such as chicken, fish, and greens among African-Americans. Cultural influences on food intake usually lessen if the woman and her family become more integrated into the dominant culture. Nutrition beliefs and the practices of selected cultural groups are summarized in Table 4.

 

Table 4 Characteristic Food Patterns of Selected Cultures

 

Vegetarian diets

Vegetarian diets represent another cultural effect on nutritional status. Foods basic to almost all vegetarian diets are vegetables, fruits, legumes, nuts, seeds, and grains. However, there are many variations in vegetarian diets. Semivegetarians, who are not truly vegetarians, include fish, poultry, eggs, and dairy products in their diets but do not eat beef or pork. Such a diet can be completely adequate for pregnant women. Besides plant products, lactoovovegetarians also eat dairy products. Iron and zinc intake may not be adequate in these women, but such diets can be otherwise nutritionally sound. Strict vegetarians, or vegans, consume only plant products. Because vitamin B12 is found only in foods of animal origin, this diet is therefore deficient in vitamin B12. As a result, strict vegetarians should take a supplement or consume vitamin B12-fortified foods (e.g., soy milk) regularly. Vitamin B,2 deficiency can result in megaloblastic anemia, glossitis, and neurologic deficits in the mother. Infants born to affected mothers are likely to have megaloblastic anemia and exhibit neurodevelopmental delays. Iron, calcium, zinc, and vitamin B6 intake may also be low in women on this diet, and some strict vegetarians have excessively low caloric intakes. The protein intake should be assessed especially carefully because plant proteins tend to be incomplete, in that they lack one or more amino acids required for growth and the maintenance of body tissues. The daily consumption of a variety of different plant proteins (e.g., grains, dried beans and peas, nuts, seeds) helps provide all the essential amino acids.

 

EVALUATION

When weight gain is inadequate or nutritional deficits appear, the nurse must assess the woman and her understanding of her nutritional needs, reinforce teaching as needed, and continue to reevaluate regularly (see Plan of Care).

 

PLAN OF CARE Nutrition During Pregnancy

NURSING DIAGNOSIS Deficient knowledge related to nutritional requirements during pregnancy

Expected Outcome The patient will delineate nutritional requirements and exhibit evidence of incorporating requirements into diet.

Nursing Interventions/Rationales

Review basic nutritional requirements for a healthy diet using recommended dietary guidelines and the food guide pyramid to provide knowledge baseline for discussion.

Discuss increased nutrient needs (calories, protein, minerals, vitamins) that occur as a result of being pregnant to increase knowledge needed for altered dietary requirements.

Discuss the relationship between weight gain and fetal growth to reinforce interdependence of fetus and mother.

Calculate the appropriate total weight gain range during pregnancy using the woman’s body mass index as a guide and discuss recommended rates of weight gain during the various trimesters of pregnancy to provide concrete measures of dietary success.

Review food preferences, cultural eating patterns or beliefs, and prepregnancy eating patterns to enhance integration of new dietary needs.

Discuss how to fit nutritional needs into usual dietary patterns and how to alter any identified nutritional deficits or excesses to increase chances of success with dietary alterations.

Discuss food aversions or cravings that may occur during pregnancy and strategies to deal with these if they are detrimental to fetus (e.g., pica) to ensure well-being of fetus.

Have woman keep a food diary delineating eating habits, dietary alterations, aversions, and cravings to track eating habits and potential problem areas.

 

NURSING DIAGNOSIS Imbalanced nutrition: more than body requirements related to excessive intake and/or inadequate activity levels

Expected Outcome The patient’s weekly weight gain will be reduced to the appropriate rate using her body mass index (BMI) and recommended weight gain ranges as guidelines.

Nursing Interventions/Rationales

Review recent diet history (including food cravings) using a food diary, 24-hour recall, or food frequency approach to ascertain food excesses contributing to excess weight gain.

Review normal activity and exercise routines to determine level of energy expenditure; discuss eating patterns and reasons that lead to increased food intake (e.g., cultural beliefs or myths, increased stress, boredom) to identify habits that contribute to excess weight gain.

Review optimal weight gain guidelines and their rationale to ensure that the woman is knowledgeable about healthful weight gain rates.

Set target weight gains for the remaining weeks of the pregnancy to establish set goals.

Discuss with the woman what changes can be made in diet, activity, and lifestyle to enhance chances of meeting weight gain goals and dietary needs. Weight reduction diets should be avoided, since they may deprive the mother and fetus of needed nutrients and lead to ketonemia.

 

NURSING DIAGNOSIS (mbalanced nutrition: less than body requirements related to inadequate intake of needed nutrients

Expected Outcome The patient’s weekly weight gain will be increased to the appropriate rate using her BMI and recommended weight gain ranges as guidelines.

Nursing Interventions/Rationales

Review recent diet history (including food aversions) using a food diary, 24-hour recall, or food frequency approach to ascertain dietary inadequacies contributing to lack of sufficient weight gain.

Review normal activity and exercise routines to determine level of energy expenditure; discuss eating patterns and reasons that lead to decreased food intake (e.g., morning sickness, pica, fear of becoming fat, stress, boredom) to identify habits that contribute to inadequate weight gain.

Review optimal weight gain guidelines and their rationale to ensure that woman is knowledgeable about healthful weight gain rates.

Set target weight gains for the remaining weeks of the pregnancy to establish set goals.

Review increased nutrient needs (calories, protein, minerals, vitamins) that occur as a result of being pregnant to ensure woman is knowledgeable about altered dietary requirements.

Review relationship between weight gain and fetal growth to reinforce that adequate weight gain is needed to promote fetal well-being.

Discuss with woman what changes can be made in diet, activity, and lifestyle to enhance chances of meeting set weight gain goals and nutrient needs of mother and fetus.

If woman has fear of being fat, if symptoms of an eating disorder are evident, or if problems in adjusting to a changing body image surface, refer woman to the appropriate mental health professional for evaluation, since intensive treatment and follow-up may be required to ensure maternal and fetal health.