FAMILY NURSING

Family Nursing with Childbearing Families

LEARNING OBJECTIVES

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

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

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

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

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

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

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

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

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

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

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

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

DIAGNOSIS OF PREGNANCY

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

SIGNS AND SYMPTOMS

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

ESTIMATING DATE OF BIRTH

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

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

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

ADAPTATION TO PREGNANCY

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

MATERNAL ADAPTATION

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

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

Accepting the pregnancy

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

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

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

Identifying with the mother role

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

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

Reordering personal relationships

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

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

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

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

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

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

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

Establishing a relationship with the fetus

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

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

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

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

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

Preparing for childbirth

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

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

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

PATERNAL ADAPTATION

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

Accepting the pregnancy

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

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

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

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

Identifying with the father role

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

Reordering personal relationships

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

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

Establishing a relationship with the fetus

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

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

Preparing for childbirth

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

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

SIBLING ADAPTATION

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

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

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

Box 9 Tips for Sibling Preparation

PRENATAL

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

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

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

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

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

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

DURING THE HOSPITAL STAY

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

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

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

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

GOING HOME

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

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

ADJUSTMENT AFTER THE BABY IS HOME

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

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

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

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

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

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

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

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

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

GRANDPARENT ADAPTATION

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

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

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

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

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

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

CARE MANAGEMENT

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

Assessment and Nursing Diagnoses

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

Initial Visit

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

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

762-2264.)

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

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

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

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

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

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

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

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

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

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

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

LEGAL TIP Drug Screening in Pregnancy

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

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

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

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

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

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

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

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

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

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

Prenatal Physical Examination

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

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

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

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

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

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

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

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

Follow-up visits

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

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

References

1. Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.

2. Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2^nd Edition) St. Louis: Mosby-Elsevier.

Recommended Optional Materials/References

3. Hitchcock, J.E., Schubert, P.E, & Thomas S.A. (1999) Community Health Nursing: Caring in Action / Delmar.

4. American Psychological Association. (1994) Publication Manual of the American Psychological Association (4th ed.). Washington, DC: Author.

See required Websites:

http://www.health.gov/healthypeople/.

www.health.state.mn.us/divs/chs/phn/definitions.pdf