Ch. 8 Nursing Care of the Family During Pregnancy

Countering Misinformation

Many myths and much of the misinformation related to sex and pregnancy are masked by seemingly unrelated issues.

Clean-catch urine

Specimen is obtained to test for levels of glucose, protein, nitrites, and leukocytes at each visit.

Harmful affects of Cigarette Smoking

-Cigarette smoking or continued exposure to secondhand smoke (even if the mother does not smoke) is associated with IUGR and an increase in perinatal and infant morbidity and mortality. -Smoking can affect fertility and may lead to a greater risk for ectopic pregnancy. -Smoking is associated with an increased incidence of spontaneous abortion, ectopic pregnancy, preterm birth, PROM, abruptio placentae, placenta previa, and fetal death. -All women who smoke should be strongly encouraged to quit or at least reduce the number of cigarettes they smoke. -Pregnant women should be told about the negative effects of secondhand smoke on the fetus and encouraged to avoid such environments.

Reordering Personal Relationships

-Close relationships of the pregnant woman undergo change as she prepares emotionally for the new role of mother. -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 adapting to pregnancy and motherhood. -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.

Personal Hygiene

-During pregnancy, the sebaceous (sweat) glands are highly active because of hormonal influences and women often perspire freely. -Baths and warm showers can be therapeutic because they relax tense, tired muscles; help counter insomnia; and make the pregnant woman feel fresh. -ub bathing is permitted even in late pregnancy because little water enters the vagina unless under pressure. -Tub bathing is contraindicated after rupture of the membranes.

Women older than 35

-One group consists of women who have many children or who have an additional child during the menopausal period. -The other group consists of women who have deliberately delayed childbearing until their late 30s or early 40s. -The U.S. birth rate for women who are 40 to 44 years of age was 10.2 births per 1000 women, which is the highest rate since 1967. -The birth rate for women 45 to 49 years of age is stable at 0.7 births per 1000 women

Emotional Lability

-Rapid and unpredictable changes in mood. -Increased irritability, explosions of tears and anger, and feelings of great joy and cheerfulness alternate, apparently with little or no provocation. -Profound hormonal changes that are part of the maternal response to pregnancy may be responsible for mood changes.

Paternal preparation for Childbirth

-The days and weeks immediately before the expected day of birth are characterized by anticipation and anxiety. -They are able to channel the anxiety and other feelings experienced during the final weeks before birth into productive activities. -Major concerns for the man are getting the mother to the birthing facility in time for the birth and not appearing ignorant. -With the exception of childbirth preparation classes, a man has few opportunities to learn ways to be an involved and active partner in this rite of passage into parenthood. -Birth partners need to be kept informed, supported, and included in all activities in which the mother desires their participation.

Accepting the Pregnancy

-The degree of acceptance is reflected in the woman's emotional responses. -Eventual acceptance of pregnancy parallels the growing acceptance of the reality of a child. -Women who are happy and pleased about their pregnancy have high self-esteem and tend to be confident about outcomes for themselves, their babies, and other family members.

Potential Complications that need attention immediately

-f she senses that something is wrong, she should call her care provider immediately. -Several signs and symptoms must be discussed more extensively. -These include vaginal bleeding, alteration in fetal movements, symptoms of preeclampsia, rupture of membranes, and preterm labor.

Identifying with the Father Role

-Some men are highly motivated to nurture and love a child. -Others may be more detached or even hostile to the idea of fatherhood.

Multifetal Pregnancy

-A multifetal pregnancy, or pregnancy with more than one fetus, places the mother and fetuses at increased risk for adverse outcomes. -The maternal blood volume is increased, resulting in an increased strain on the maternal cardiovascular system. -Placenta previa develops more commonly in multifetal pregnancies because of the large size or placement of the placentas. -Twin pregnancies often end prematurely. -The mother needs nutrition counseling so that she gains more weight than that needed for a singleton birth. -Fetal growth is carefully monitored throughout pregnancy using regular ultrasound evaluations. -Iron and vitamin supplements are desirable. -Every multifetal pregnancy is at risk for preterm labor; thus the women receive frequent ultrasound examinations, FHR monitoring, and nonstress tests. Routine bedrest is not recommended in twin pregnancies at low risk for preterm labor. -If bedrest is recommended, the mother needs to assume the lateral position to promote increased placental perfusion. If birth is delayed until after the thirty-sixth week, the risk for morbidity and mortality decreases for the neonates.

History of Drugs and Herbal Preparations

-A woman's past and present use of drugs, both legal OTC, prescriptions, and herbal drugs; caffeine; alcohol; nicotine and illegal (marijuana, cocaine, heroin), must be assesed because many substances cross the placenta and can harm the developing fetus. -It is important for health care providers to question pregnant women regarding the use of herbal preparations and document their responses.

Kegel Exercises

-Alternate contracting and relaxing of the pelvic floor muscles to strengthen the muscles around the reproductive organs and improve muscle tone. -The pelvic floor muscles encircle the vaginal outlet, and they need to be exercised. -Practice of pelvic muscle exercise during pregnancy also results in fewer complaints of urinary incontinence in late pregnancy and postpartum.

Drugs

-Any drug or environmental agent that enters the pregnant woman's bloodstream has the potential to cross the placenta and harm the fetus. -Although substance abuse in pregnancy is a major public health concern and comprehensive care of drug-addicted women improves maternal and neonatal outcomes, few facilities are available for treatment of these women.

Harmful affects of Alcohol

-Ethanol (alcohol) is a powerful teratogen that can have devastating effects on the developing fetus (e.g., fetal alcohol syndrome). -Women who are pregnant or considering pregnancy should totally abstain from alcohol.

Physical Activity

-Physical activity promotes a feeling of well-being and can help reduce anxiety in the pregnant woman. -The U.S. Department of Health and Human Services (USDHHS) recommends 150 minutes of moderate exercise each week during pregnancy for women who are not already active or engaging in moderate exercise.

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. -Additional research is needed on a variety of families to determine if study findings generated in traditional families are applicable to others.

Pregnancy

-Pregnancy spans 9 calendar months. -Health care providers use the concept of lunar months, which last 28 days (or 4 weeks), to describe the duration of pregnancy or gestational age. -Thus normal pregnancy lasts about 10 lunar months, that is, 40 weeks, or 280 days.

Posture and Body Mechanics

-Skeletal, musculature, and hormonal changes in pregnancy can predispose the woman to backache and possible injury. -Poor posture and body mechanics contribute to the discomfort and potential for injury.

Immunizations

-Some concern has been raised over the safety of various immunization practices during pregnancy. -Immunization with live or attenuated live virus or live bacterial vaccines is generally contraindicated during pregnancy.

Education for self-Management

-The expectant mother needs information on many topics. -Pregnant women who receive conflicting advice or instruction are likely to grow increasingly frustrated with members of the health care team and the care provided.

Primiparous Women

-The number of first-time pregnancies in U.S. women between ages 35 and 40 years has increased significantly over the past three decades. -Reasons for delaying pregnancy include a desire to obtain advanced education, career priorities, and use of better contraceptive measures. -These women choose parenthood. -First-time mothers older than 35 years select the "right time" for pregnancy; this time is influenced by their awareness of the increasing possibility of infertility or of genetic defects in the infants of older women. -Women 35 years of age and older are more likely than younger primiparas to have infants with chromosomal abnormalities, LBW infants, preterm birth, abruptio placentae, and multiple gestation. -In addition, in women ages 35 years or older, there is an increased risk for maternal mortality from hemorrhage, infection, embolisms, hypertensive disorders of pregnancy, cardiomyopathy, and strokes.

Fetal Assesment

-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. -The health status of the fetus is assessed at each visit for the remainder of the pregnancy.

Collaborative Care

After obtaining information through the assessment process, the data are analyzed to identify deviations from the norm and unique needs of the pregnant woman and her family.

Clothing

Although most cultural groups do not prescribe specific clothing for pregnancy, modesty is an expectation for many.

Sexual Activity

In most cultures, sexual activity is not prohibited until the end of pregnancy.

Nutrition

Such a conflict commonly is not known by health care providers unless they understand the dietary beliefs and practices of the particular people for whom they are caring.

Using the History

The couple's sexual history provides a basis for counseling, but history taking also is an ongoing process.

Abruptio Placentae (placental separation)

The detachment of part or all of a normally implanted placenta from the uterus before the birth of the infant.

Contraindicated Live Vaccines

-Measles (Rubeola and Rubella) -Chickenpox (Varicella) -Sabin (oral) poliomyelitis (No longer used in the U.S.) -Human Papilloma Virus (HPV)

Adolescents

-Teenage pregnancy is a worldwide problem. The United States has one of the highest teen birth rates among industrialized nations. -Characteristics of programs that make a difference are those that have sustained commitment to adolescents over a long period, 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. -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 for LBW, neglect and abuse, serious and long-term disability, and dying during the first year of life.

Multiparous Women

Multiparous women may have never used contraceptives because of personal choice or a lack of knowledge concerning contraceptives.

Age differences

The age of the childbearing couple may have a significant influence on their physical and psychosocial adaptation to pregnancy.

Childbearing and female Reproductive System History

-Data are gathered on the woman's age at menarche; menstrual history; contraceptive history; history of infertility or gynecologic conditions; history of any STIs; her sexual history; and a detailed history of all her pregnancies, including the present one, and their outcomes. -The date of the last Papanicolaou (Pap) test and the result are noted. -The date of her LMP is obtained to establish the EDB.

Air Travel

-Air travel in large commercial jets usually poses little risk to the pregnant woman, but policies vary from airline to airline. -Most health care providers allow air travel up to 36 weeks of gestation in women without medical or pregnancy complications. -Women at risk for preterm labor should avoid air travel. - Magnetometers (metal detectors) used at airport security checkpoints are not harmful to the fetus. -The 8% humidity at which cabins are maintained in commercial airlines may result in some water loss; hydration (with water) should be maintained under these conditions. -A pregnant woman is encouraged to take a 15-minute walk around the aircraft during each hour of travel to minimize this risk.

History of Physical Abuse

-All women should be assessed for a history of or risk for physical abuse, particularly because the likelihood of intimate partner violence (IPV) increases during pregnancy. -It is essential that the screening is done in a safe, private setting with the woman alone. -Although visual cues from the woman's appearance or behavior may suggest the possibility of abuse, no one profile of the battered woman exists. -Women report physical blows directed to the head, breasts, abdomen, and genitalia. Sexual assault is common. -Routine screening for abuse and sexual assault is recommended for pregnant adolescents. -Nurses should be aware that victims of human trafficking may be seen in prenatal settings because of unintended pregnancy.

Physical parameters measured at each visit

-BP is taken at every visit, using the same arm and with the woman seated. -Weight is measured, and the appropriateness of the weight gain is evaluated in relation to her BMI. -Urine may be checked by dipstick. -The presence and degree of edema are noted. -Abdominal inspection is followed by measurement of the height of the fundus.

Healthy Pregnancy

If women can be taught healthy lifestyle behaviors and then practice them before conception—specifically, good nutrition, entering pregnancy with as healthy a weight as possible, adequate intake of folic acid, avoidance of alcohol and tobacco use, prevention of sexually transmitted infections (STIs) and other health hazards.

Couvade Syndrome

Pregnancy-related ritual or a cluster of symptoms experienced by some prospective fathers during pregnancy and childbirth.

Group Prenatal Care

-An alternative model to traditional care during pregnancy. -Authority is shifted from the provider to the woman and other women who have similar due dates. -The model creates an atmosphere that facilitates learning, encourages discussion, and develops mutual support. -Centering Pregnancy, is a well-known model of group prenatal care that involves three components: health care assessment, education, and peer support. -Families and partners are encouraged to participate. -Benefits associated with group prenatal care include improved birth outcomes such as lower rates of preterm birth, increased knowledge, improved satisfaction, and higher breastfeeding initiation rates

Nägele's rule

-Method for calculating the estimated date of birth (EDB) or "due date". Also called Naegele's rule. -Because the exact date of conception is usually unknown, several formulas have been suggested for calculating the EDB. -After determining the first day of the LMP, subtract 3 months, add 7 days and 1 year; or add 7 days to the LMP and count forward 9 months. -Assumes that the woman has a 28-day menstrual cycle and that the pregnancy occurred on the fourteenth day of the cycle.

Follow-up Visits

-Monthly visits are scheduled routinely during the first and second trimesters, although additional appointments may be made as the need arises. -Starting with week 28, visits are scheduled every 2 weeks until week 36; then visits are scheduled every week until birth unless the health care provider individualizes the schedule.

Education About Maternal and Fetal Changes

-Mothers may be more tolerant of the discomforts related to the continuing pregnancy if they understand the underlying causes. -To be most effective, the materila should be appropriate for the pregnant woman's or couple's ethnicity, culture, and literacy level and the agency's resources.

Physical Activity and Rest

-Norms that regulate physical activity of mothers during pregnancy vary tremendously. -It is important for the nurse to find out the way each pregnant woman views activity and rest.

Initial Visit

-Once the pregnancy is confirmed and the woman's desire to continue the pregnancy has been validated, prenatal care is begun. -Assessment techniques include the interview, physical examination, and laboratory tests.

Paternal Adaptation

-One man may engage in nurturing behavior; another may feel lonely and alienated as the woman becomes physically and emotionally engrossed in the unborn child. -Some men view pregnancy as a proof of their masculinity and their dominant role. -For most men, pregnancy is a time of preparation for the parental role, fantasy, great pleasure, and intense learning.

Recognizing potential complications

-One of the most important responsibilities of care providers is to alert the pregnant woman to signs and symptoms that indicate a potential complication of pregnancy. -Pregnant women often have difficulty deciding when to report signs and symptoms.

Mother-Child Relationship through pregnancy Developmental Process in 3 phases.

-Phase 1: Accepts the biologic fact of pregnancy. Can state, "I am pregnant." -Phase 2: Accepts the growing fetus as distinct from herself and as a person to nurture. Can state, " I am going to have a baby." -Phase 3: The woman prepares realisticallly for the birth and parenting of the child. Can state, " I am going to be a mother."

Phases characterizing the developmental tasks experienced by the expectant father

-Phase 1: The announcement phase may last from a few hours to a few weeks. Men react to the confirmation of pregnancy with joy or dismay, depending on whether the pregnancy is desired, unplanned, or unwanted. -Phase 2: The moratorium phase, is the period when he adjusts to the reality of pregnancy. They become more introspective and engage in many discussions about their philosophy of life, religion, childbearing, and childrearing practices and their relationships with family members, particularly with their father. -Phase 3: The focusing phase, begins in the last trimester and is characterized by the father's active involvement in both the pregnancy and his relationship with his child. In this phase, the man concentrates on his experience of the pregnancy and begins to think of himself as a father.

Family History

-Provides information about the woman's family, including parents, grandparents, 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.

Follow-up Physical Examination

-Reevaluation is a constant aspect of a pregnant woman's care. -Physiologic changes are documented as the pregnancy progresses and reviewed for possible deviations. -The information provided during the interview and physical examination reflects the status of maternal adaptations. -When any of the findings is suspicious, an in-depth examination is performed.

Caffeine

-Research findings suggest that caffeine intake less than 200 mg per day during pregnancy does not appear to be a major contributing factor to miscarriage or preterm birth. -Women should be aware of the caffeine content of foods, drinks, and certain OTC medications and should intentionally limit their intake as recommended.

Suggesting Alternative Behaviors

-Research has not demonstrated that coitus and orgasm are contraindicated at any time during pregnancy for the obstetrically and medically healthy woman. -However, a history of more than one miscarriage; a threatened miscarriage in the first trimester; impending miscarriage in the second trimester; and PROM, bleeding, or abdominal pain during the third trimester warrant caution regarding coitus and orgasm. -Showing the woman or couple illustrations of the possible variations of coital position is helpful. -During the third trimester, the side-by-side position or any position that places less pressure on the pregnant abdomen and requires less energy may be preferred.

Sexual Counseling

-Sexual counseling of expectant couples includes countering misinformation, providing reassurance of normality, and suggesting alternative behaviors. -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, have the myths that are associated with sex during pregnancy dispelled, and participate in open discussions of positions for intercourse that decrease pressure on the gravid abdomen. -Couples whose long-standing problems with sexual dysfunction are intensified by pregnancy are good candidates for sex therapy.

Sibling Adaptation

-Sharing the spotlight with a new brother or sister may be the first major crisis for a child. -A mother with other children must devote time and energy to reorganizing her relationships with these children. -A mother with other children must devote time and energy to reorganizing her relationships with these children. -Sibling responses to pregnancy vary with age and dependency needs.

Social, Experimental, and Occupational History

-Situational factors such as the family's ethnic and cultural background and socioeconomic status are assessed while the history is obtained. -The woman's perception of this pregnancy is explored. -The family support system is determined. -During interviews throughout the pregnancy, the nurse should remain alert for the appearance of potential parenting problems such as depression, lack of family support, and inadequate living conditions. -Coping mechanisms and patterns of interacting are identified. -Before planning for nursing care, the nurse needs information about the woman's decision-making abilities and living habits (e.g., exercise, sleep, diet, diversional interests, personal hygiene, clothing). -Explore attitudes concerning the range of acceptable sexual behavior during pregnancy. -Women should be questioned regarding their occupation, past and present, since this may adversely affect maternal and fetal health.

Clothing

-Some women continue to wear their usual clothes during pregnancy as long as they fit and feel comfortable. -Comfortable, loose clothing is best. Tight bras and belts, stretch pants, garters, tight-top knee socks, body shapers, 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). -Maternity support (compression) hose give considerable comfort and promote greater venous emptying in women with large varicose veins. -Comfortable shoes that provide firm support and promote good posture and balance are advisable.

Recognizing Preterm Labor

-Teaching each expectant mother to recognize preterm labor is necessary for early diagnosis and treatment. -Preterm labor occurs after the twentieth week but before the thirty-seventh week of pregnancy. -It consists of uterine contractions that, if untreated, cause the cervix to dilate and efface earlier than normal, resulting in preterm birth.

Killed Virus Vaccines okay during Pregnancy

-Tetanus -Diptheria -Recombinant Hepatitis B -Influenza vaccines -The optimal timing for the vaccine is between 27 and 36 weeks of gestation.

Sibling Responses to Pregnancy

-The 1-year-old infant seems largely unaware of the process. -The 2-year-old child notices the change in the mother's appearance. -Toddlers may exhibit more clinging behavior and revert to dependent behaviors in toilet training or eating. -By age 3 or 4 years, children like to be told the story of their own beginning and accept its being compared to the present pregnancy. -They like to listen to heartbeats and feel the baby moving in utero -School-age children take a more clinical interest in their mother's pregnancy. Tthey 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. -Late adolescents do not appear to be unduly disturbed. They realize that they soon will be gone from home. -Parents usually report that late adolescents are comforting and act more like other adults than children.

Fetal Laboratory Tests

-The number of routine laboratory tests done during follow-up visits in pregnancy is limited. -Other diagnostic tests, such as amniocentesis, are available to assess the health status of both the pregnant woman and the fetus

Nutritional History

-The nutritional status of a pregnant woman has a direct effect on the growth and development of the fetus. -It is essential that obese women receive counseling about weight gain, nutrition, and food choices. -Women with a history of bariatric surgery are nutritionally at risk and should be followed closely throughout pregnancy to promote maternal and fetal well-being

Reordering Paternal Personal Relationships

-The partner's main role in pregnancy is to nurture the pregnant woman and to respond supportively to her feelings of vulnerability. -The partner's support indicates involvement in the pregnancy and preparation for attachment to the child. -Feelings of rivalry may be unconscious and not verbalized but expressed in subtle behaviors.

Rest and Relaxation

-The pregnant woman is encouraged to plan regular rest periods, particularly as pregnancy advances. -Conscious relaxation is the process of releasing tension from the mind and body through deliberate effort and practice. -The ability to relax consciously and intentionally can be beneficial. -The techniques for conscious relaxation are numerous and varied.

Current Pregnancy

-The presumptive signs of pregnancy, such as nausea and vomiting, 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.

Identifying with the Mother Role

-The process of identifying with the mother role begins early in each woman's life when she is being mothered as a child. -Their high motivation to become a parent promotes acceptance of pregnancy and eventual prenatal and parental adaptation.

Sexual Expression during Pregnancy

-The sexual relationship is affected by physical, emotional, and interactional factors, including misinformation 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. -Partners need to feel free to discuss their sexual responses during pregnancy with each other and with their health care provider.

Travel

-Travel is not contraindicated for low risk pregnant women. -Travel to areas where medical care is poor, water is untreated, or malaria is prevalent should be avoided if possible. -Women who contemplate foreign travel should be aware that many health insurance carriers do not cover birth in a foreign setting or even hospitalization for preterm labor. -Vaccinations for foreign travel may be contraindicated during pregnancy.

Emotional Response

-Virtually all cultures emphasize the importance of maintaining a socially harmonious and agreeable environment for the pregnant woman. -A lifestyle with minimal stress is important in ensuring a successful outcome for the mother and baby.

Estimating Date of Birth

-When pregnancy is confirmed, the woman's first question usually concerns when she will give birth. -To promote a more positive perception of both pregnancy and birth, the term estimated date of birth (EDB) is now used. -Accurate dating of pregnancy and calculation of the EDB have implications for timing of specific prenatal screening tests, assessing fetal growth, and making critical decisions for managing pregnancy complications. -Nägele's rule assumes that the woman has a 28-day menstrual cycle and that the pregnancy occurred on the fourteenth day of the cycle. -Only about 5% of pregnant women give birth spontaneously on the EDB as determined by Nagele's rule. -Most women give birth during the period extending from 7 days before to 7 days after the EDB.

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. -Pregnancy is a maturational milestone that can be stressful but also rewarding as the woman prepares for a new level of caring and responsibility. -She moves gradually 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.

Fundal Height

-During the second trimester, the uterus becomes an abdominal organ. -The fundal height, or measurement of the height of the uterus above the symphysis pubis, is used as one indicator of fetal growth. -The measurement also provides a gross estimate of the duration of pregnancy. -The fundal height measurement may aid in the identification of risk factors. -A stable or decreased fundal height may indicate the presence of intrauterine growth restriction (IUGR); an excessive increase could indicate the presence of multifetal gestation (more than one fetus) or polyhydramnios (excessive amniotic fluid).

Establishing a Relationship with the Fetus

-Emotional attachment—feelings of being tied by affection or love—begins during the prenatal period as women use fantasizing and daydreaming to prepare themselves for motherhood. -They try to anticipate changes that the child will bring in their lives and wonder how they will react to noise, disorder, reduced freedom, and caregiving activities -Providing an accepting environment for parental reactions facilitates the parents' ability to move beyond disappointment to acceptance.

Employment

-Employment of pregnant women usually has no adverse effects on pregnancy outcomes. -Pregnant women should not perform any job that subjects them to severe physical strain or exposes them to harmful substances. -Job discrimination that is based solely on pregnancy is illegal. -Women in sedentary jobs need to walk around at intervals to counter the sluggish circulation in the legs. -They should avoid crossing their legs at the knees because all of these activities can foster the development of varices and thrombophlebitis. -Standing for long periods also increases the risk for preterm labor.

Medications and Herbal preparations

-Although much has been learned in recent years about fetal drug toxicity, the possible teratogenicity of many prescription and OTC drugs is still unknown. -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. -The use of all drugs, including OTC medications, herbs, and vitamins, should be limited; and a careful record should be kept of all therapeutic and nontherapeutic agents used. -There is limited research evidence about the safety of herbal preparations, especially during pregnancy.

Prevention of Urinary Tract Infection

-Because of physiologic changes that occur in the renal system during pregnancy (see Chapter 7), infections of the lower urinary tract (acute urethritis, acute cystitis) are common. -Women should be instructed to inform their health care provider promptly if they experience these symptoms. -Urinary tract infections pose a risk to the mother and fetus; thus their prevention or early treatment is essential. -Advise her to drink at least 2 liters (L) (eight glasses) of liquid a day to maintain an adequate fluid intake that ensures frequent urination. -The consumption of yogurt and acidophilus milk can help prevent urinary tract and vaginal infections. -Women should be told not to ignore the urge to urinate, because holding urine lengthens the time bacteria are in the bladder and allows them to multiply. -Bacteria also can be introduced during intercourse.

Second Trimester Screenings

-Between 15 and 20 weeks, maternal serum alpha-fetoprotein (MSAFP) screening, the QUAD test (alpha-fetoprotein, hCG, estriol, and inhibin A), or Penta Screen (components of QUAD test plus invasive trophoblast antigen [ITA]) can be done to screen for neural tube defects (NTDs) and other chromosomal abnormalities. -An ultrasound is often done at 18 to 24 weeks to survey fetal anatomy. -If the cervix is confirmed to be short, further assessment for preterm birth risk factors should occur and management options should be considered.

Human Trafficking

-Coercion or deception of individuals (usually women and children) to perform commercial sex acts or forced labor. -They are under strict control by their traffickers. -Similar to victims of IPV, these women are likely to exhibit signs of physical abuse or neglect such as scars, bruises, burns, unusual bald patches, or tattoos that may be a sign of branding.

Cultural Prescriptions and Proscriptions

-Cultural Prescriptions; Tell women what to do. -Cultural Proscriptions; Establish taboos. -The purposes of these practices are to prevent maternal illness caused by a pregnancy-induced imbalanced state and to protect the vulnerable fetus. - Prescriptions and proscriptions regulate the woman's emotional response, clothing, physical activity and rest, sexual activity, and dietary practices.

Dental Health

-Dental care during pregnancy is especially important because nausea during pregnancy may lead to poor oral hygiene and allow dental caries to develop. -Inflammation and infection of the gingival an periodontal tissues may occur. -Diagnosis and treatment of oral health problems, including necessary dental x-rays, are safe during pregnancy. -Dental care and nonemergent procedures are best scheduled during the second trimester when the woman is past the stage of feeling nauseous and can sit comfortably in the dental chair.

Review of Systems

-During the review of systems, ask the woman to identify and describe pre-existing or concurrent problems in any of the body systems and assess her mental status. -Pregnancy affects and is affected by all body systems; therefore information on the present status of body systems is important in planning care.

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. -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. -Other issues of concern that can arise for the pregnant woman and couple include fear of pain, loss of control, and possible birth of the infant before reaching the hospital. -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. -Providing the prospective mother and father with opportunities to discuss their concerns and validating the normality of their responses can meet their needs to some degree.

Grandparent Adaptation

-Every pregnancy affects all family relationships. -In some family units, expectant grandparents are nonsupportive and may inadvertently decrease the self-esteem of the parents-to-be. -Most grandparents are delighted with the prospect of a new baby in the family. -Their satisfaction and that of the parents come with the realization that continuity between past and present is guaranteed. -The grandparent's presence and support can strengthen family systems by widening the circle of support and nurturance

First Trimester Screenings

-First-trimester screening for chromosomal abnormalities is offered as an option between 11 and 14 weeks. This multiple marker screen includes ultrasound evaluation of nuchal translucency (NT) and biochemical markers—pregnancy-associated placental protein (PAPP-A) and free beta-human chorionic gonadotropin (β-hCG).

Follow-up Interviews

-Follow-up visits are less intensive than the initial prenatal visit. -She is asked about her general emotional and physical well-being, complaints or problems, and questions she may have. -During the third trimester, the nurse needs to assess the parents' understanding of the following: the warning signs that indicate emergencies such as bleeding and abdominal pain, the signs of preterm and term labor, the labor process and anxieties about labor, fetal development, and methods to assess fetal well-being. -A review of the woman's physical systems is appropriate at each visit, and any suggestive signs or symptoms are assessed in depth.

Nutrition

-Good nutrition is important in the maintenance of maternal health during pregnancy and in the provision of adequate nutrients for embryonic and fetal development. -Assessing a woman's nutritional status and weight gain and providing information on nutrition are part of the nurse's responsibilities in providing prenatal care. -Teaching may include discussion about foods high in iron, encouragement to take prenatal vitamins, and recommendations to limit caffeine intake. -Nurses can refer women to a registered dietitian if a need is identified during the nursing assessment.

Things to remember to help prevent UTI

-Harsh, scented or printed toilet paper may cause irritation. -Bubble baths or other bath oils should be avoided because these can irritate the Urethra. -Women should wear underpants and panty hose with a cotton crotch and avoid wearing tight fighting slacks or jeans for long periods. -Anything that allows buildup of heat and moisture in the genital area can foster the growth of bacteria.

Ambivalence

-Having conflicting feelings at the same time—is considered a normal response for people preparing for a new role. -Body sensations, feelings of dependence, or the realization of the responsibilities of child care also can generate such feelings.

Third Trimester Screenings

-If not done earlier in pregnancy, a glucose screen is obtained between 24 and 28 weeks of gestation for women at high risk for gestational diabetes. -Group B strep (GBS) testing is done between 35 and 37 weeks of gestation; cultures collected earlier will not accurately predict GBS status at time of birth. -Tests that are often repeated at 28 weeks include hemoglobin and hematocrit, serologic test for syphilis, and HIV testing. -At 28 weeks, an Rh type and screen for antibodies is performed. -Hematocrit testing may be repeated at 36 weeks in women with anemia and those at risk for peripartum hemorrhage

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 results.

Paternal Adaptation Accepting the Pregnancy

-In older societies, the man enacted the ritual couvade; that is, he behaved in specific ways and respected taboos associated with pregnancy and giving birth. -Now some men experience pregnancy-like symptoms, such as nausea, weight gain, and other physical symptoms.

Cultural Influences

-Many cultural variations are found in prenatal care. -A concern for modesty is a deterrent to many women seeking prenatal care. -For many cultural groups, a physician is deemed appropriate only in times of illness. -Western medicine's view of problems in pregnancy may differ from that of members of other cultural groups. -Although pregnancy is considered normal by many, certain practices are expected of women of all cultures to ensure a good outcome.

Preparing for Childbirth

-Many women actively prepare for birth. -Anxiety can arise from concern about safe passage for herself and her child during the birth process. -These feelings persist despite statistical evidence about the safe outcome of pregnancy for mothers and their infants. -Toward the end of the third trimester, breathing is difficult and fetal movements become vigorous enough to disturb the mother's sleep. -Backaches, frequency and urgency of urination, constipation, and varicose veins can become troublesome. -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.

Car Travel

-Maternal death as a result of injury is the most common cause of fetal death. -The next most common cause is placental separation (abruptio placentae) that occurs because body contours change in reaction to the force of a motor vehicle collision. -A combination lap belt and shoulder harness is the most effective automobile restraint, and both should be used. - The lap belt should be worn low across the hip bones and as snug as is comfortable (Fig. 8-17). The shoulder harness should be worn above the gravid uterus and below the neck to prevent chafing.

Preparation for Breastfeeding the Newborn

-The American Academy of Pediatrics (AAP) Recommends exclusive breastfeeding for the first 6 months, continued breastfeeding as complementary feedings are introduced, and breastfeeding for at least 1 year and beyond as desired by the mother and infant. -Most women who chose to breastfeed do so because they are aware of the numerous benefits. -Modesty issues, lack of support by the partner, and family, incompatibility with lifestyle, and lack of confidence are among the reasons cited by women who decide to formula feed their infants. -Assessment of breasts during the prenatal period may reveal potential concerns related to breastfeeding. -Breast stimulation is contraindicated in women at risk for preterm labor. -The woman is taught to cleanse the nipples with warm water to prevent blocking of the ducts with dried colostrum. -Soap, ointments, alcohol, and tinctures should not be applied because they remove protective oils that keep nipples supple.

Fetal Health Status

-The assessment of fetal health status includes consideration of fetal movement. -The fetal heart rate (FHR) is checked on routine visits once it has been heard. -Early in the second trimester, the heartbeat may be heard with the Doppler stethoscope. -The heartbeat is counted for 1 minute, and the quality and rhythm are noted. -Later in the second trimester, the FHR can be determined with the fetoscope or Pinard fetoscope. -A normal rate and rhythm are other good indicators of fetal health. -Intensive investigation of fetal health status is initiated if any maternal or fetal complications arise (e.g., maternal hypertension, IUGR, premature rupture of membranes [PROM], irregular or absent FHR, absence of fetal movements after quickening).

Laboratory Tests

-The data yielded by laboratory examination of specimens obtained during the examination add important information concerning the symptoms of pregnancy and the woman's health status. -Specimens are collected at the initial visit so that any abnormal findings can be treated. -Testing for antibody to the human immunodeficiency virus (HIV) is strongly recommended for all pregnant women; this testing must be voluntary and without coercion. -The folate level is measured when indicated. -Cystic fibrosis (CF) carrier screening tests should be offered to all pregnant women; if the woman is a CF carrier, the father of the baby should be tested. -During the pelvic examination, cervical and vaginal smears can be obtained for cytologic studies and for diagnosis of infection. -Recognition of risk factors during pregnancy may indicate the need to repeat some tests at other times. -STIs are common in pregnancy and may have negative effects on mother and fetus. -Careful assessment and thorough screening are essential.

Establishing a Paternal 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. -Men prepare for fatherhood in many of the same ways that women prepare for motherhood. -Some men become involved by choosing the child's name and anticipating the child's sex if it is not already known.

Quickening

-The first movements of the fetus in the uterus felt by the mother. -It usually occurs between weeks 16 and 20 of gestation and is initially experienced as a fluttering sensation.

Cognitive Restructuring

-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. -Intense feelings of ambivalence that persist through the third trimester can indicate an unresolved conflict with the motherhood role

Care Management

-The goal of prenatal care is to promote the health and well-being of the pregnant woman, her fetus, the newborn, and the family. -Although women of middle or high socioeconomic status routinely seek prenatal care, women living in poverty or those who lack health insurance are not always able to use public health care services or gain access to private care. -Lack of culturally sensitive care providers and barriers in communication caused by differences in language also interfere with access to care. -Barriers to obtaining health care during pregnancy include a lack of motivation to seek care, especially for unintended pregnancies; inadequate finances; lack of transportation; unpleasant clinic personnel, facilities, or procedures; inconvenient clinic hours; child care problems; and personal attitudes. -The initial visit usually occurs in the first trimester, with monthly visits through week 28 of pregnancy. Thereafter, visits are scheduled every 2 weeks until week 36 and then every week until birth. -Prenatal care is ideally a multidisciplinary activity in which nurses work with nurse-midwives, nutritionists, physicians, social workers, and others. -If women can be taught healthy lifestyle behaviors and then practice them before conception—specifically, good nutrition, entering pregnancy with as healthy a weight as possible, adequate intake of folic acid, avoidance of alcohol and tobacco use, prevention of sexually transmitted infections (STIs) and other health hazards—a healthier pregnancy may result.

Health History

-The health history includes those physical or surgical procedures that can affect the pregnancy or that can be affected by the pregnancy. -The woman should also describe any previous surgical procedures. -Note any injury involving the pelvis. -Observations are a vital component of the interview process because they prompt the nurse and the woman to focus on the specific needs of the woman and her family.

Initial Visit Interview

-The initial evaluation includes a comprehensive health history emphasizing the current pregnancy, previous pregnancies, the family, a psychosocial profile, a physical assessment, diagnostic testing, and an overall risk assessment. -Two types of data are collected: the woman's subjective appraisal of her health status and the nurse's objective observations. -Observations and information about the woman's partner and/or family are then included in the database.

Initial Physical Examination

-The initial physical examination provides the baseline for assessing subsequent changes. -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 (BP), height, and weight (for calculation of body mass index [BMI]) -Heart and lung sounds are evaluated, and extremities are examined. -The skin is assessed for changes in pigmentation, rashes, and edema. -Distribution, amount, and quality of body hair are of particular importance because the findings reflect nutritional status, endocrine function, and attention to hygiene. -Particular attention is paid to the size of the uterus because this is an indication of the duration of gestation. -One vaginal examination during pregnancy is recommended; another is usually not done unless indicated for medical reasons.

Diagnosis of Pregnancy

A correct date for the first day of the last (normal) menstrual period (LMP), the date of intercourse, and a basal body temperature record can be of great value in the accurate diagnosis of pregnancy