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Nursing care during pregnancy

June 14, 2024

Nursing care during pregnancy. Childbirth and Perinatal education

LEARNING OBJECTIVES

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

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

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

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

* Discuss 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.

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 in nurturing their infants. The father-child attachment also begins during pregnancy. A father may rub or kiss the maternal abdomen, try to listen to the fetus, or play with the fetus as he notes fetal movement.

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

Preparing for childbirth

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

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

SIBLING ADAPTATION

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

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

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

Box 9

Tips for Sibling Preparation

PRENATAL

1. Take your child on a prenatal visit. Let the child listen to the fetal heartbeat and feel the baby move.

2. Involve the child in preparations for the baby, such as helping decorate the baby’s room.

3. Move the child to a bed (if still sleeping in a crib) at least 2 months before the baby is due.

4. Read books, show videos, and/or take child to sibling preparation classes, including a hospital tour.

5. Answer your child’s questions about the coming birth, what babies are like, and any other questions.

6. Take your child to the homes of friends who have babies so that the child has realistic expectations of what babies are like.

DURING THE HOSPITAL STAY

1. Have someone bring the child to the hospital to visit you and the baby (unless you plan to have the child at tend the birth).

2. Do not force interactions between the child and the baby. Often the child will be more interested in seeing you and being reassured of your love.

3. Help the child explore the infant by showing how and where to touch the baby.

4. Give the child a gift (from you or you, the father, and b y).

GOING HOME

1. Leave the child at home with a relative or baby-sitter.

2. Have someone else carry the baby from the car so that you can hug the child first.

ADJUSTMENT AFTER THE BABY IS HOME

1. Arrange for a special time with the child alone with each parent.

2. Do not exclude the child during infant feeding times.The child can sit with you and the baby and feed a doll or drink juice or milk with you or sit quietly with a game.

3. Prepare small gifts for the child so that when the baby gets gifts, the sibling won’t feel left out. The child can also help open the baby gifts.

4. Praise the child for acting age appropriately (so that being a baby does not seem better than being older).

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

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

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

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

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

GRANDPARENT ADAPTATION

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

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

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

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

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

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

CARE MANAGEMENT

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

Assessment and Nursing Diagnoses

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

Initial Visit

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

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

762-2264.)

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

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

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

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

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

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

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

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

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

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

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

LEGAL TIP Drug Screening in Pregnancy

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

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

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

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

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

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

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

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

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

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

Prenatal Physical Examination

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

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

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

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

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

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

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

Table 1 Laboratory Tests in Prenatal Period

Laboratory test

Purpose

Hemoglobin/hematocrit/white blood cell count, differential

Detects anemia/detects infection

Hemoglobin electrophoresis

Identifies women with hemoglobinopathies (e.g., sickle cell anemia, thalassemia)

Blood type, Rh, and irregular antibody

Identifies those fetuses at risk for developing erythroblastosis fetalis or hyperbilirubinemia in neonatal period

Rubella titer

Determines immunity to rubella

Tuberculin skin testing; chest film after 20 weeks of gestation in women with reactive tuberculin tests

Screens for exposure to tuberculosis

Urinalysis, including microscopic examination of urinary sediment; pH, specific gravity, color, glucose, albumin, protein, RBC, white blood cell count, casts, acetone; hCG

Identifies women with unsuspected diabetes mellitus, renal disease, hypertensive disease of pregnancy; infection; pregnancy

Urine culture

Identifies women with asymptomatic bacteriuria

Renal function tests: BUN, creatinine, electrolytes, creatinine clearance, total protein excretion

Evaluates level of possible renal compromise in women with a history of diabetes, hypertension, or renal disease

Pap test

Screens for cervical intraepithelial neoplasia, herpes simplex type 2, and HPV

Vaginal or rectal smear for Neisseria gonorrhoeae, Chlamydia, HPV, GBS

Screens high risk population for asymptomatic infection GBS done at 35-37 weeks

RPR/VDRL/FTA–ABS

Identifies women with untreated syphilis

HIV* antibody, hepatitis B surface antigen, toxoplasmosis

Screens for infection

1-hour glucose tolerance

Screens for gestational diabetes; done at initial visit for women with risk factors; done at 24 to 28 weeks for all pregnant women

3-hour glucose tolerance

Screens for diabetes in women with elevated glucose level after 1-hour test; must have two elevated readings for diagnosis

Cardiac evaluation: ECG, chest x–ray film, and echo–cardiogram

Evaluates cardiac function in women with a history of hypertension or cardiac disease

BUN, Blood urea nitrogen; ECG, electrocardiogram; FTA-ABS, fluorescent treponemal antibody absorption test; GBS, group B streptococcus; hCG, human chorionic gonadotropin; HIV, human immunodeficiency virus; HPV, human papillomavirus; RPR, rapid plasma reagin.

Follow-up visits

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

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

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

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

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

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

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

EMERGE IM C Y

Supine H y p o t 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 oon-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 than normal, and it can result in preterm birth. Although certain factors, such as multifetal pregnancy, may increase a woman’s chances of going into preterm labor, the specific cause (or causes) is not known. If the woman knows the warning signs and symptoms of preterm labor and seeks care early enough, should they occur, it may be possible to prevent a preterm birth. Warning signs and symptoms of preterm labor are given in the Self-Care box. Fig. 19 shows where in the body the symptoms of preterm labor may be located.

Patient Instructions for Self-Care

How to Recognize Preterm Labor

Because the onset of preterm labor is subtle and often hard to recognize, it is important to know how to feel your abdomen for uterine contractions. You can feel for contractions in the following way. While lying down, place your fingertips on the top of your uterus. A contraction is the periodic tightening or hardening of your uterus. If your uterus is contracting, you will actually feel your abdomen get tight or hard and then feel it relax or soften when the contraction is over.

If you think you are having any of the other signs and symptoms of preterm labor, empty your bladder, drink three to four glasses of water for hydration, lie down tilted toward your side, and place a pillow at your back for support.

Check for contractions for 1 hour. To tell how often contractions are occurring, check the minutes that elapse from the beginning of one contraction to the beginning of the next.

It is not normal to have frequent uterine contractions (every 10 minutes or more often for 1 hour).

Contractions of labor are regular, frequent, and hard. They also may be felt as a tightening of the abdomen or a backache. This type of contraction causes the cervix to efface and dilate.

Call your doctor, nurse-midwife, clinic, or labor and birth unit, or go to the hospital if any of the following signs occur:

* You have uterine contractions every 10 minutes or more often for 1 hour or

* You have any of the other signs and symptoms for 1 hour or

* You have any bloody spotting or leaking of fluid from your vagina

It is often difficult to identify preterm labor. Accurate diagnosis requires assessment by the health care provider, usually in the hospital or clinic.

Post these instructions where they can be seen by everyone in the family.

Sexuality in Pregnancy

* Be aware that maternal physiologic changes, such as breast enlargement, nausea, fatigue, abdominal changes, perineal enlargement, leukorrhea, pelvic vasocongestion, and orgasmic responses, may affect
sexuality and sexual expression.

* Discuss responses to pregnancy with your partner.

* Keep in mind that cultural prescriptions (dos) and proscriptions (don’ts) may affect your responses.

* Although your libido may be depressed during the first trimester, it increases during the second and third trimesters.

* Discuss and explore with your partner:

-Alternative behaviors (e.g., mutual masturbation, foot massage, cuddling)

-Alternative positions (e.g., female superior, side-lying) for sexual intercourse

* Intercourse is safe as long as it is not uncomfortable. There is no correlation between intercourse and miscarriage, but observe the following precautions:

-Abstain from intercourse if you experience uterine cramping or vaginal bleeding; report event to your caregiver as soon as possible.

-Abstain from intercourse (or any activity that results in orgasm) if you have a history of cervical incompetence, until it is corrected.

* Continue to use safer sex behaviors. Women at risk for acquiring or transmitting sexually transmitted infections are encouraged to use condoms during sexual intercourse throughout pregnancy.

Fig. 19 Symptoms of preterm labor.

Sexual counseling

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

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

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

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

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

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

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

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

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

Psychosocial support

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

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

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

Evaluation

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

PLAN Of CARE Discomforts of Pregnancy and Warning Signs

FIRST TRIMESTER

NURSING DIAGNOSIS Deficient knowledge related to schedule of prenatal visits throughout pregnancy as evidenced by patient questions and concerns

Expected Outcome: Patient will verbalize correct appointment schedule for the duration of the pregnancy.

Nursing Interventions/Ratinales

Provide information regarding schedule of visits, tests, and other assessments and interventions that will be provided throughout the pregnancy to empower patient to function in collaboration with the caregiver.

NURSING DIAGNOSIS Imbaianced nutrition: less than body requirements, related to nausea and vomiting as evidenced by patient report and weight loss

Expected Outcome Patient will gain 7 to 2.5 kg during the first trimester.

Nursing Interventions/Ratinales

Verify prepregnant weight to plan a diet realistic according to individual patient’s nutritional needs.

Obtain diet history to identify current meal patterns and foods that may be implicated 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 in normal 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 oonpharmacologic 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

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.