Chapter 13 Adaptations to Pregnancy

Maternal Tasks of Pregnancy

1.Seeking safe passage for herself and the baby through pregnancy, labor, and childbirth 2.Securing acceptance of the baby and herself by her partner and family 3.Learning to give of herself 4.Developing attachment and interconnection with the unknown child

Emotional Response

1st trimester :Uncertainty, ambivalence, focus on self 2nd trimester: Wonder, increased narcissism, introversion, concern about changes in her body and sexuality 3rd trimester: Vulnerability, increased dependence, acceptance that fetus is separate but totally dependent

Role

1st trimester: May begin to seek safe passage for self and fetus 2nd trimester: Seeks acceptance of fetus and her role as mother 3rd trimester: Prepares for birth

Physical Validation

1st trimester: No obvious signs of fetal growth 2nd trimester: Quickening, enlarging abdomen 3rd trimester: Obvious fetal growth, discomfort, decreased maternal activity

Toddlers and pregnancy

2 years or younger usually advisable to tell young child just before birth that a new brother or sister is coming The nurse can make suggestions about helping prepare young children for the birth and what to expect from toddlers when the new baby comes home. Changes in sleeping arrangements should be made several weeks before the birth so the child does not feel displaced by the new baby. Parents need to realize that toddlers may have feelings of jealousy and resentment when they must share attention with a baby. Frequent reassurances of parental love and affection are of primary importance.

Probable indications of pregnancy

Abdominal enlargement Abdominal or uterine tumors Cervical softening (Goodell's sign) Hormonal imbalance, hormonal contraceptives Ballottement Uterine or cervical polyps Braxton Hicks contractions Intestinal gas Palpation of fetal outline Large leiomyomas (fibroids) (may feel like the fetal head); small, soft leiomyoma (may simulate small parts of the fetus) Uterine souffle Confusion with mother's pulse Pregnancy tests Incorrect procedure, testing too early, urine too dilute, certain medications, hematuria, proteinuria, or malignant tumors that produce human chorionic gonadotropins

Family's Response to pregnancy: resources

Affluent: Is confident of ability, has financial reserves to protect from economic fluctuations, owns or rents home in a safe neighborhood, has health insurance or can pay for health care, able to provide enriched environment Middle Class: Has relative security, but fewer reserves and more debt, owns or rents home in relatively safe neighborhood, depends on employment for health insurance Working poor or unemployed: Lacks skills and bargaining power, is most vulnerable to economic fluctuations, struggles to meet basic needs New poor: Was previously self-sufficient, but has lost prior resources, may have recently lost job and insurance, unused to public assistance

Time Orientation

Affluent: Is future oriented and seeks prenatal care early, expects best possible care and education for children Middle Class: Is future oriented and seeks early prenatal care, makes plans to provide best possible care and education for children Working Poor/unemployed: Priority is to meet needs of present, often seeks prenatal care late, uncertain future New poor: Has middle-class time orientation but must meet present needs, may begin prenatal care late

Values place on preventive care

Affluent: Values preventive care Middle Class: Values health care but must rely on health insurance related to employment Working poor/ unemployed: May value health care but often does not see a way to improve situation New Poor: Values health care but may no longer have finances to access it

Ovaries and pregnancy

After conception, the major function of the ovaries is to secrete progesterone from the corpus luteum for the first 6 to 7 weeks of pregnancy. Progesterone is called the hormone of pregnancy because adequate progesterone must be available from the earliest stages if the pregnancy is to be maintained. The corpus luteum secretes progesterone until the placenta is developed. Once developed, the placenta produces progesterone throughout pregnancy. Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) necessary for ovulation.

hCS

Also called human placental lactogen (hPL) hCS increases the availability of glucose for the fetus. An insulin antagonist, hCS reduces the sensitivity of maternal cells to insulin. This decreases maternal metabolism of glucose, thereby freeing glucose for transport to the fetus. In addition, hCS promotes the mobilization and use of free fatty acids to provide energy for the pregnant woman.

Presumptive Indications of Pregnancy

Amenorrhea Emotional stress, strenuous physical exercise, endocrine problems, chronic disease, early menopause, low body weight Nausea and vomiting Gastrointestinal virus, food poisoning, emotional stress Fatigue Illness, stress, sudden changes in lifestyle Urinary frequency Urinary tract infections Breast and skin changes Premenstrual changes, use of oral contraceptives Vaginal and cervical color changes (Chadwick's sign) Infection or hormonal imbalance Quickening Intestinal gas, peristalsis, or pseudocyesis (false pregnancy)

isoimmunization

Antibody tests may be repeated in the third trimester in women who are Rh negative if the father of the baby is Rh positive. If unsensitized, the woman should receive Rho(D) immune globulin prophylactically at 28 weeks of gestation

Gynecologic and Contraceptive History

Any previous gynecologic problems should be identified. Sexually transmitted diseases should be treated. Infertility problems with past or the present pregnancy should be discussed. A detailed history of contraceptive methods is important.

Dependent Edema

As many as 70% of women have dependent edema during pregnancy. Water accumulation of edema varies from 1.5 to 5 L. not necessarily clinical insignificant with no abnormal signs Fluid retention is also associated with carpal tunnel syndrome, believed to result when edema compresses the median nerve at the point where it passes through the carpal tunnel of the wrist.

Hegar's Sign

At 6 to 8 weeks after the last menses, the lower uterine segment (the isthmus) is so soft that it can be compressed to the thinness of paper.

Positive Indications of Pregnancy

Auscultation of fetal heart sounds Fetal movements felt by examiner Visualization of embryo or fetus

Uterus Growth Summary

Before conception, the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. It weighs up to 70 g (2.5 oz) and has a capacity of approximately 10 mL (one third of an ounce). By full term (the end of normal pregnancy) the uterus weighs approximately 1100 to 1200 g (2.4 to 2.6 lb) and has a capacity of approximately 5000 mL (Norwitz & Lye, 2009). Uterine growth occurs as the result of hyperplasia and hypertrophy. Growth can be predicted for each trimester (one of three 13-week periods of pregnancy). During the first trimester, growth is mainly a result of hyperplasia caused by stimulation from estrogen and growth factors. During the second and third trimesters, uterine growth is caused by hyperplasia and hypertrophy as the muscle fibers stretch to accommodate the growing fetus. Fibrous tissue accumulates in the outer muscle layer of the uterus, and the amount of elastic tissue increases. These changes greatly increase the strength of the muscle wall (Cunningham, Leveno, Bloom, et al., 2010). Muscle fibers in the myometrium increase in both length and width. By the third trimester, the uterine muscles are thin, and the fetus can be easily palpated through the abdominal wall.

Glucose Screen

Blood glucose is often screened at 24 to 28 weeks by a glucose challenge test. If the result is elevated, the woman has a glucose tolerance test to detect gestational diabetes may not be necessary in women younger than 25 year or who are at low risk for developing gestational diabetes

Cutaneous Vascular Changes

Blood vessels dilate and proliferate during pregnancy, an effect of estrogen. Changes in surface blood vessels are obvious during pregnancy, especially in women with fair skin. These include spider angiomas that appear as tiny red elevations that branch in all directions. Redness of the palms or soles of the feet, known as palmar erythema, also occurs in many white women and in some African-American women. Vascular changes may be emotionally distressing for the expectant mother, but they are clinically insignificant and usually disappear shortly after childbirth.

Chadwich's Sign

Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion.

Breast evaluation

Breast size and symmetry, the condition of the nipples (erect, flat, inverted), and the presence of colostrum should be noted. Any lumps, dimpling of the skin, or asymmetry of the nipples requires further evaluation.

Uterine Souffle

Can be checked late in pregnancy a soft, blowing sound may be auscultated over the uterus. This is the sound of blood circulating through the dilated uterine vessels, and it corresponds to the maternal pulse. Therefore to identify the uterine souffle, the rate of the maternal pulse must be checked simultaneously.

Goodell's sign

Collagen fibers in the connective tissue of the cervix decrease, causing the cervix to soften. Before pregnancy, the cervix has a consistency similar to that of the tip of the nose. After conception, the cervix feels more like the lips or earlobe.

traditional schedule for prenatal assessment

Conception to 28 weeks: Every 4 weeks 29 to 36 weeks: Every 2 weeks 37 weeks to birth: Weekly

High Risk Factors - Existing Medical Conditions

Diabetes mellitus Increased risk for preeclampsia, cesarean birth, preterm birth, infant small or large for gestational age, neonatal hypoglycemia, congenital anomalies Hypothyroidism Increased incidence of preeclampsia, abruptio placenta, low birthweight, preterm birth, and stillbirth Hyperthyroidism Maternal risk for preeclampsia, thyroid storm, or postpartum hemorrhage Cardiac disease Maternal risk for cardiac decompensation and death; increased risk for fetal and neonatal death Renal disease Maternal risk for renal failure and preterm delivery; fetal risk for intrauterine growth restriction Concurrent infections Increased incidence of spontaneous abortion or congenital anomalies (heart disease, blindness, deafness, bone lesions) if maternal disease occurred in the first trimester SIDS, Sudden infant death syndrome.

Nausea and Vomiting

During pregnancy approximately 60% to 80% of women experience nausea and vomiting symptoms usually begin 4 to 8 weeks after gestation

Eye and Pregnancy

During pregnancy, corneal edema causes thickening, which may result in discomfort for women who wear contact lenses. The problem resolves during the postpartum, so women should not get new prescriptions for lenses for several weeks after delivery.

Pituitary Gland

During pregnancy, prolactin from the anterior pituitary increases to prepare the breasts to produce milk. FSH and LH are suppressed because they are not needed to stimulate ovulation during pregnancy. The posterior pituitary produces oxytocin, which stimulates the milk-ejection reflex after childbirth. Oxytocin also stimulates contractions of the uterus, but during pregnancy, this action is inhibited by progesterone, which relaxes smooth muscle fibers of the uterus. After childbirth, progesterone levels decline when the placenta is removed, and oxytocin keeps the uterus contracted, preventing excessive bleeding at the placental site.

Adrenal Gland

During pregnancy, significant changes occur in two adrenal hormones: cortisol and aldosterone. Free (unbound) cortisol, the metabolically active form, is elevated. Cortisol regulates carbohydrate and protein metabolism. It stimulates gluconeogenesis (formation of glucose from noncarbohydrate sources such as amino or fatty acids) whenever the supply of glucose is inadequate to meet the mother's needs for energy. Aldosterone regulates the absorption of sodium from the distal tubules of the kidneys. It increases during pregnancy to overcome the salt-wasting effects of progesterone to maintain the necessary level of sodium in the greatly expanded blood volume and to meet the needs of the fetus. Aldosterone is closely related to water metabolism.

Kidneys & Ureters and Pregnancy

During pregnancy, the kidneys change in both size and shape because of dilation of the renal pelves, calyces, and ureters above the pelvic brim. The dilation is caused by (1) the effect of progesterone, which causes the ureters to become elongated and more distensible; and (2) compression of the ureters between the enlarging uterus and the bony pelvic brim. Renal blood flow increases by 50% to 80% by the middle of pregnancy, then decreases as the pregnancy progresses to term The increases in renal plasma flow and GFR are necessary for excretion of additional metabolic waste from the mother and fetus, but they also affect the excretion of glucose, amino acids, electrolytes, and water-soluble vitamins. Increased risk of UTI. Mild proteinuria is common and does not necessarily mean there is abnormal kidney function or preeclampsia

Vulnerability

During the third trimester and particularly during the seventh month, pregnant women have increasing feelings of vulnerability many expectant mothers have fantasies or nightmare about harm coming to their infant

Abdominal Wall

During the third trimester, the abdominal muscles may become so stretched that the rectus abdominis muscles separate (diastasis recti). The extent of the separation varies from slight, which is clinically insignificant, to severe, when a large portion of the uterine wall is covered only by peritoneum, fascia, and skin

Narcissism and Introversion

During this time many women become increasingly concerned about their ability to protect and provide for the fetus. This concern is often manifested as narcissism (undue preoccupation with oneself) and introversion (concentration on oneself and one's body).

Uterine Blood Flow

Early in pregnancy blood flow is relatively low, with it's primary target being the myometrium and endometrium

Mouth and Pregnancy

Elevated levels of estrogen cause hyperemia of the tissues of the mouth and gums, which may lead to gingivitis and bleeding gums. Some women experience ptyalism (excessive salivation)

Stomach and Pregnancy

Elevated levels of progesterone relax all smooth muscle, decreasing gastrointestinal tone and motility.

Estrogen

Estrogen causes increased vascularity of the mucous membranes of the upper respiratory tract. As the capillaries become engorged, edema and hyperemia develop within the nose, pharynx, larynx, and trachea. This congestion may result in nasal and sinus stuffiness, epistaxis (nosebleed), and deepening of the voice. Increased vascularity also causes edema of the eardrum and eustachian tubes, which may result in a sense of fullness in the ears or earaches.

High Risk - obstetric

FACTORS IMPLICATIONS Demographic Factors Younger than 16 years or older than 35 years of age Increased risk for preterm labor, preeclampsia, congenital anomalies, infant mortality Low socioeconomic status or dependent on public assistance Increased risk for preterm birth, low-birth-weight infants Nonwhite race Increased incidence of preterm birth and infant and maternal death for some groups Multiparity Higher parity increases risk for antepartum or postpartum hemorrhage, cesarean birth Social-Personal Factors Low prepregnancy weight Associated with low-birth-weight infants Obesity Increased risk for hypertension, prolonged labor, large-for-gestational-age infant, cesarean birth, wound infections, gestational diabetes, thromboembolic disorders, and postpartum hemorrhage Height less than 152 cm (5 ft) Increased incidence of cesarean birth because of cephalopelvic disproportion Smoking Associated with placenta previa, abruptio placentae, premature membrane rupture, spontaneous abortion, perinatal mortality, low-birth-weight, preterm birth, SIDS Use of alcohol or unprescribed drugs Increased risk for congenital anomalies, neonatal withdrawal, fetal alcohol syndrome Obstetric Factors Birth of previous infant more than 4000 g (8.8 lb) Increased need for cesarean birth; increased risk for infant birth injury, maternal gestational diabetes, neonatal hypoglycemia Previous preterm birth Increased incidence of repeated preterm birth Previous fetal or neonatal death Maternal psychological distress Rh sensitization Fetal anemia, erythroblastosis fetalis, kernicterus

Auscultation of Fetal Heart Sounds

Fetal heart sounds can be heard with a stethoscope by 16 to 20 weeks of gestation. The electronic Doppler may detect heart motion and makes an audible sound as early as 9 weeks. The heartbeat can be seen on ultrasound as early as 8 weeks you need to make sure distinguish between the mothers and fetal heart rate, need to take mother's radial pulse during auscultation fetal heart rate should be between 110 and 160 during the third trimester

GTPAL

G stands for pregnancies or gravida; T, term births or pregnancies delivered between 38 and 42 weeks of gestation; P, preterm births (births between the 20th and 38th week of gestation); A, abortions; and L, living children.

Thyroid Gland

Hyperplasia and increased vascularity cause the thyroid gland to enlarge during pregnancy. Early in the first trimester, a rise in total serum thyroxine (T4) and thyroxine-binding globulin occurs. The level of serum free (unbound) T4 rises in early pregnancy and then returns to normal. Maternal thyroid hormones are important in the development of the fetal brain. The basal metabolic rate (BMR) increases up to 25% primarily because of the fetal metabolic activity

Estrogen

In early pregnancy, estrogen is produced by the corpus luteum. It is produced primarily by the placenta for the remainder of pregnancy. Estrogen has numerous functions during pregnancy: (1) It stimulates uterine growth and increases blood supply to uterine vessels; (2) it aids in developing the ductal system in the breasts in preparation for lactation; and (3) it is associated with hyperpigmentation, vascular changes in the skin, increased activity of the salivary glands, and hyperemia of the gums and nasal mucous membranes.

hCG

In early pregnancy, human chorionic gonadotropin (hCG) is produced by the trophoblastic cells that surround the developing embryo. The rapid increase of this hormone stimulates the corpus luteum to produce progesterone and estrogen until the placenta is sufficiently developed to assume that function at about 10 to 12 weeks after conception (Blackburn, 2008). It also causes a positive pregnancy test result.

Integumentary System

Increased pigmentation from elevated estrogen, progesterone, and melanocyte-stimulating hormone may begin as early as the 8th week. Areas of pigmentation include brownish patches, called melasma, chloasma, or the mask of pregnancy, over the forehead, cheeks, and nose. Melasma may also occur in women taking oral contraceptives. It increases with exposure to sunlight, but use of sunscreen may reduce the severity. The linea alba (the line that marks the longitudinal division of the midline of the abdomen) darkens to become the linea nigra

Hot Tubs and Saunas

Instruct the expectant mother to avoid activities that may cause maternal hyperthermia A pregnant woman should not stay in a sauna for more than 15 minutes or a hot tub for more than 10 minutes and should keep her head, arms, and upper chest out of the water

Braxton Hicks Contractions

Irregular, painless contractions occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. As the woman nears the end of pregnancy, the contractions become stronger and more frequent. These are sometime confused with preterm labor. If the woman has more than 5 or 6 contractions in an hour or is unsure, should contact her HCP.

The search for a role fit

Looking for a role fit occurs once the woman has built a set of role expectations for herself and has internalized a view of a "good" mother's behavior. This process implies that the woman has explored the role of mother long enough to develop a sense of herself in the role and to be able to select behaviors that reaffirm her sense of herself fulfilling the role.

High Risk Factors - Social Personal

Low prepregnancy weight Associated with low-birth-weight infants Obesity Increased risk for hypertension, prolonged labor, large-for-gestational-age infant, cesarean birth, wound infections, gestational diabetes, thromboembolic disorders, and postpartum hemorrhage Height less than 152 cm (5 ft) Increased incidence of cesarean birth because of cephalopelvic disproportion Smoking Associated with placenta previa, abruptio placentae, premature membrane rupture, spontaneous abortion, perinatal mortality, low-birth-weight, preterm birth, SIDS Use of alcohol or unprescribed drugs Increased risk for congenital anomalies, neonatal withdrawal, fetal alcohol syndrome

mutlifetal pregnancy

More than one fetus should be suspected if the fundal height is 4 cm or more greater than expected on the basis of gestational age Women who are older, African-American, have a personal or family history of twins, or have conceived using infertility therapy have an increased chance of multifetal pregnancies separate fetuses and heart arteries by 6 weeks

Postural Changes

Musculoskeletal changes are progressive. They begin in the second trimester, when the hormones estrogen and progesterone initiate increased mobility of the pelvic ligaments. This facilitates passage of the fetus through the pelvis at the time of birth. At 28 to 30 weeks, the pelvic symphysis separates. Relaxation of the pelvic joints creates pelvic instability, and the woman may assume a wide stance and the waddling gait of pregnancy to compensate for a changing center of gravity. During the third trimester, as the uterus increases in size, the expectant mother leans backward to maintain her balance. This posture creates a progressive lordosis, or curvature of the lower spine, and may lead to backache. Obesity or previous back problems increases the problem.

Oxygen Consumption and Pregnancy

Oxygen consumption increases by approximately 20% in pregnancy. Half the oxygen is used by the uterus, fetus, and placenta.

Parathyroid Gland

Parathyroid hormone, important for calcium homeostasis, decreases during the first trimester but then increases steadily throughout pregnancy (Cunningham et al., 2010). Calcium for transfer to the fetus is adequate.

Plasma Volume and Pregnancy

Plasma volume increases progressively from 6 to 8 weeks of gestation until approximately 32 weeks. This is an increase of 40% to 60% (1200 to 1600 mL) above nonpregnant values. Increases are greater in multifetal pregnancies.

Progesterone

Progesterone and prostaglandins play a role in decreasing airway resistance by relaxing smooth muscle in the respiratory tract. Progesterone is also believed to raise the sensitivity of the respiratory center (medulla oblongata) to carbon dioxide, thus stimulating the increase in minute ventilation. These two factors are responsible for the heightened awareness of the need to breathe experienced by many pregnant women.

Liver and Gallbladder and Pregnancy

Progesterone causes functional changes of the liver and gallbladder. The gallbladder becomes hypotonic and emptying time is prolonged, resulting in thicker bile and predisposing to the development of gallstones. Reduced gallbladder tone also leads to a tendency to retain bile salts, which can cause itching (pruritus) During the last trimester the liver is pushed upward and backward by the enlarging uterus. Serum alkaline phosphatase rises to two to four times that of nonpregnant women and levels of serum albumin and total protein fall

Progesterone

Progesterone is produced first by the corpus luteum and then by the fully developed placenta. The major functions include: •Maintaining the endometrial layer for implantation of the fertilized ovum •Preventing spontaneous abortion by relaxing the smooth muscles of the uterus •Preventing tissue rejection of the fetus •Stimulating the development of the lobes and lobules in the breast in preparation for lactation •Facilitating the deposit of maternal fat stores, which provide a reserve of energy for pregnancy and lactation •Relaxing smooth muscle of the uterus and other areas (gastric sphincter, intestines, ureters, and bladder) •Increasing respiratory sensitivity to carbon dioxide, stimulating ventilation •Suppressing the immunologic response, preventing rejection of the fetus

RBC and pregnanc

RBC mass increases by 250 to 450 mL, approximately 20% to 30% above prepregnancy values/ The increase in plasma volume is more pronounced and occurs earlier than the increase in RBC volume. The resulting dilution of RBC mass causes a decline in maternal hemoglobin and hematocrit. This condition is frequently called physiologic anemia or pseudoanemia of pregnancy because it reflects the dilution of RBCs in an expanded plasma volume rather than an actual decline in the number of RBCs.

One of the most common nursing diagnosis during the prenatal period

Readiness for Enhanced Childbearing Process: prenatal health practices that provide optimal benefit to the fetus and mother.

Readiness for fatherhood

Readiness for fatherhood is more likely if there is a stable relationship between the partners, financial security, and a desire for parenthood. Additional factors include the man's relationship with his own father, his previous experience with children, and his confidence in his ability to care for the infant. other paternal concerns include the health of the mother and baby, financial concerns, and worry about his role during the birth and about the changes that will result from the birth of the baby

Psychological Response: First trimester: uncertainty, ambivalence, mood changes, self as primary focus Second trimester: wonder, joy, focus on fetus Third trimester: vulnerability, preparing for birth (fear, anger, apathy, ambivalence, lack of preparation)

Sample Questions: "How do you and your partner feel about being pregnant?" "How will the pregnancy change your lives?" "How do you feel about the changes in your body?" "What are you doing to get ready for the baby?" Nursing Implications: Use active listening and reflection to establish a sense of trust. Reevaluate negative responses (fear, apathy, anger) in subsequent assessments.

Educational Needs: Many questions about pregnancy, childbirth, and infant care (no questions, absence of interest in educational programs)

Sample Questions: "How do you feel about caring for an infant?" "What are your major concerns?" "Who do you ask for information?" Nursing Implications: Respond to expressed needs. Refer couple to appropriate classes and reliable Internet sources of information.

Changes in Sexual Practice: Mutual satisfaction with changes (excessive concern with comfort or safety, excessive conflict)

Sample Questions: "How has your sexual relationship changed during the pregnancy?" "How do you cope with the changes?" "What concerns you most?" Nursing Implications: Offer reassurance that intercourse is safe in normal pregnancy. Suggest alternative positions and open communication.

Availability of Resources: Financial concerns (lack of funds or insurance) Availability of grandparents, friends, family (family geographically or emotionally unavailable)

Sample Questions: "What are your plans for prenatal care and birth?" "How do your parents feel about being grandparents?" "Who else can you depend on besides the family?" "Who helps you when there is a problem?" Nursing Implications: Determine adequacy of financial means. Refer to resources such as a public clinic for care, WIC for food. Help the couple discover alternative resources if the family is unavailable. Identify family conflicts early to allow time for resolution.

Cultural Influences: Ability of either the woman or her family to speak English or availability of fluent interpreters, cultural influences that support a healthy pregnancy and infant (harmful cultural beliefs or health practices)

Sample Questions: "What foods and practices are recommended during pregnancy?" "What is forbidden?" "What is most important to you in your care?" "How do your religious beliefs affect pregnancy?" Nursing Implications: Locate fluent interpreters if needed. Avoid labeling beliefs as superstition. Reinforce beliefs that promote a good pregnancy outcome. Elicit help from accepted sources of information to overcome harmful practices.

Stretch Marks

Striae gravidarum or "stretch marks" appear as slightly depressed pink to purple streaks on the abdomen, breasts, and buttocks.

Common Lab Tests Table 13-3

TEST PURPOSE SIGNIFICANCE Blood grouping with Rh factor and antibody screen To determine blood type screen for possible maternal-fetal blood incompatibility Identifies possible causes of maternal-fetal blood incompatibility. If father is Rh positive and mother is Rh negative and unsensitized, Rho(D) immune globulin will be given during pregnancy and after birth Complete blood count (CBC) To identify infection, anemia, or cell abnormalities More than 15,000/mm3 white blood cells or decreased platelets require follow-up Hemoglobin (Hgb) or hematocrit (Hct) To detect anemia Often checked several times during pregnancy Low Hgb or Hct may indicate a need for added iron supplementation Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) To screen for syphilis Treat if positive. Retest if indicated. Rubella titer To determine immunity If titer is 1:8 or less, mother is not immune Immunize postpartum if not immune Tuberculin skin test To screen for tuberculosis If positive, refer for additional testing or therapy Genetic testing (for sickle cell anemia, cystic fibrosis, Tay-Sachs disease, and other genetic conditions) Offered if there is an increased risk for certain genetic conditions If mother is positive, check partner Counseling appropriate to the results of testing Hepatitis B To detect presence of antigens in maternal blood If present, infants should be given hepatitis immune globulin and vaccine soon after birth Human immunodeficiency virus (HIV) screen Voluntary test encouraged at first visit to detect HIV antibodies Positive results require retesting, counseling, and treatment to lower infant infection Urinalysis To detect renal disease or infection Requires further assessment if positive for more than trace protein (renal damage, preeclampsia), ketones (fasting or dehydration), or bacteria (infection) Papanicolaou (Pap) test To screen for cervical neoplasia Treat and refer if abnormal cells are present Cervical culture To detect group B streptococci and sexually transmitted diseases Treat and retest as necessary, treat group B streptococci during labor Multiple marker screen: Maternal serum alpha-fetoprotein, human chorionic gonadotropin, and estriol. Inhibin A may also be measured. May be combined with ultrasound. To screen for fetal anomalies Abnormal results may indicate chromosomal abnormality (such as trisomy 18 or 21) or structural defects (such as neural tube defects) Glucose challenge test To screen for gestational diabetes If elevated, a glucose tolerance test is recommended

Increasing dependence

The expectant mother often becomes increasingly dependent on her partner in the last weeks of pregnancy. Her need for love and attention from her partner is even more pronounced in late pregnancy. When she is assured of his concern and willingness to provide assistance, she feels more secure and able to cope. The nurse can encourage that couples to discuss fears and feelings openly so that misunderstandings can be avoided.

Pancreas

The higher blood glucose level makes more glucose available for fetal energy needs and stimulates the pancreas of a healthy woman to produce additional insulin. Inadequate insulin production results in gestational diabetes

Esophagus and Pregnancy

The lower esophageal sphincter tone decreases during pregnancy, primarily because of the effect of progesterone on the smooth muscles. The relaxation of the esophageal sphincter and upward displacement of the stomach allow reflux of acidic stomach contents into the esophagus and produces heartburn (pyrosis).

Partner's Health History

The partner's history may include significant health problems such as genetic abnormalities, chronic diseases, and infections. The use of drugs such as cocaine or alcohol may affect the family's ability to cope with pregnancy and childbirth. Tobacco use by the father increases the risk of upper respiratory complications as a result of passive smoke to both the mother and infant. The father's blood type and Rh factor are important if the mother is Rh-negative because a blood incompatibility between the mother and the fetus is possible.

Pattern of Uterine Growth

The uterus enlarges in a predictable pattern that provides information about fetal growth and helps to confirm the estimated date of delivery (EDD), sometimes called the estimated date of birth (EDB) (Figure 13-1). By 12 weeks of gestation, the fundus (top of the uterus) can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. It is located at the umbilicus by 20 weeks' gestation. The fundus reaches its highest level at the xiphoid process at 36 weeks. Because it pushes against the diaphragm, many expectant mothers experience shortness of breath. By 40 weeks, the fetal head descends into the pelvic cavity and the uterus sinks to a lower level. This descent of the fetal head is called lightening because it reduces pressure on the diaphragm and makes breathing easier. Lightening is more pronounced in first pregnancies.

The 5 As tactic to help expectant mothers quit smoking

They include (1) Asking women about smoking and if they would like to quit, (2) Advising women about the importance of not smoking, (3) Assessing the woman's readiness to quit, (4) Assisting women in devising a plan, and (5) Arranging follow-up visits or phone calls for ongoing counseling

Radiorecepter Assay

This test is accurate 6 to 8 days after conception. It is very sensitive and is used to detect very small amounts of hCG such as in ectopic pregnancies.

Agglutination Inhibition Test

This test uses antibodies to detect the beta subunit of hCG in blood or urine. The test is quick and ideal for early diagnosis of pregnancy. It can detect hCG in serum at very low concentrations and is positive as early as 3 to 7 days after conception.

Contractility

Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, contractions are infrequent and less noticeable. During the third trimester, contractions occur more frequently and may cause some discomfort. They are called false labor when they are mistaken for the onset of early labor.

Table 13-1

VALUE NONPREGNANT PREGNANT Red blood cell count 4.2-5.4 million/mm3 3.8-4.4 million/mm3; Decreases slightly because of hemodilution Hemoglobin 12-16 g/dL At least 11 g/dL during 1st and 3rd trimesters and at least 10.5 g/dL during 2nd trimester Hematocrit, packed cell volume 37%-47% At least 33% during 1st and 3rd trimesters and at least 32% during 2nd trimester White blood cell 5000-10,000 /mm3 5000-15,000 /mm3 Platelets 150,000-400,000/mm3 Slight decrease but within normal range Prothrombin time 11-12.5 sec Slight decrease Activated partial thromboplastin 30-40 sec Slight decrease D-dimer Negative Negative Glucose, blood Fasting 70-110 mg/dL 95 mg/dL or lower Postprandial <140 mg/dL <140 mg/dL Creatinine 0.65 ± 0.14 mg/dL 0.46 ± 0.13 mg/dL Creatinine clearance, urine 85-120 mL/min 110-150 mL/min Fibrinogen 200-400 mg/dL 300-600 g/dL

Supine Hypotension

When the pregnant woman is in the supine position, particularly during the second half of pregnancy, the weight of the gravid (pregnant) uterus partially occludes the vena cava and the aorta (Figure 13-4). The occlusion may impede return of blood from the lower extremities and reduce cardiac return, cardiac output, and blood pressure. Collateral circulation developed in pregnancy generally allows blood flow from the legs and pelvis to return to the heart when the woman is in a supine position (Blackburn, 2013). However, some women develop supine hypotensive syndrome. Symptoms include faintness, lightheadedness, dizziness, nausea, and agitation. Some may experience syncope, a brief lapse in consciousness. Turning to a lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Women should be advised to rest in a side-lying position to prevent supine hypotension. If they must lie in a supine position for any reason, a wedge or pillow under either hip is effective in decreasing supine hypotension.

High Risk Factors- Demographic

Younger than 16 years or older than 35 years of age Increased risk for preterm labor, preeclampsia, congenital anomalies, infant mortality Low socioeconomic status or dependent on public assistance Increased risk for preterm birth, low-birth-weight infants Nonwhite race Increased incidence of preterm birth and infant and maternal death for some groups Multiparity Higher parity increases risk for antepartum or postpartum hemorrhage, cesarean birth

colostrum

a thick, yellowish fluid is present beginning at 12 to 16 weeks of pregnancy and can readily be expressed from the breasts by the third trimester

Prescription and OTC Drugs

advise the expectant mother to consult with her HCP before taking any drugs

Fantasy

allows the woman to explore a variety of possibilities and daydream or "try on" a variety of behaviors. Fantasies often involve mental images of how the infant will look and what characteristics he or she will have sometimes fantasies can be fearful, i.e. what is something is wrong with baby, this makes the mother seek information and reassurance

female genital cutting

also called female circumcision or female genital mutilation. The procedure is practiced in parts of Africa, Asia, and the Middle East and is usually performed at some time during childhood. Both Christian and Muslim women may have the procedure. Performing FGC is illegal in the United States for women younger than age 18 years FGC involves removal of part or all of the clitoris, labia minora, and labia majora (called infibulation). Urinary retention, incontinence, infection, and increased morbidity and mortality during childbirth may result from female genital cutting (AWHONN, 2008). The practice has been associated with premarital chastity and is a prerequisite for marriage in some cultures. Pelvic examination is very painful because the introitus is so small and inelastic scar tissue makes the area especially sensitive. The examinations should be made as comfortable as possible by maintaining utmost privacy and draping the woman to provide maximum coverage. A pediatric speculum may be necessary because of the small vaginal opening. The woman may not give any verbal or nonverbal sign of pain, but this lack of response does not indicate an absence of pain.

Probably indications of pregnancy

are objective findings that can be documented by the examiner

Ballottement

around mid pregnancy, a sudden tap on the cervix during vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position. strong indication but could also be caused by uterine or cervical polyps

Fundal Height

bladder needs to be empty before measurement measure from upper border of symphis pubis to the top of the fundus From 16 to 18 weeks until 36 weeks, the fundal height, measured in centimeters, is approximately equal to the gestational age of the fetus in weeks

Body Image and Pregancy

body changes become very apparent during the second trimester, including bulging abdomen, thickening of the waist, and enlargement of the breast these changes may be welcomed because it is a sign of the fetus developing, or might promote a negative body image changes in body function, such as altered balance, less physical endurance, and discomfort in the pelvis and lower back areas, also affect body image.

Cardiac Output

can rise by 50 percent bpm can rise by as much as 15 to 20 beats

Heart and pregnancy

changes are minor and revert soon after giving birth

Breast changes and pregnancy

changes begin the 4th to 6th week of pregnancy: includes breast tenderness, feeling of fullness, and increased size and pigmentation of the areolae change is due to increases in estrogen and progesterone

Heart sounds and pregnancy

changes can be so altered that it would be considered abnormal in a non-pregnant person sounds are first heard between weeks 12 and 20, and soon regress after birth A systolic murmur is found in 95% of pregnant women. The murmur may persist beyond the 4th week for approximately 20% of postpartum women.

hyperemia

congestion of blood

Role Play

consists of acting out some aspects of what mothers actually do Role playing gives her an opportunity to practice the expected role and to receive validation from an observer that she has functioned well. She is particularly sensitive to the responses of her partner and her own mother.

Securing acceptance

continues throughout pregnancy involves reworking relationships so that the important persons in the family accept the woman in the role of mother and welcome the baby into the family acceptance from her mother is particularly important

adaptations of grandparents

depends on age, number and spacing of other grandchildren, and perception of role of grandparent

Changes in sexuality

during pregnancy this may increase, decrease, or remain unchanged some women may fear a miscarriage, Nurses can help reassure the couple that there is no evidence that intercourse is related to pregnancy loss when no other complications are present. In the second trimester, women experience increased sensitivity of the labia and clitoris and increased vaginal lubrication from pelvic vasocongestion. Orgasm may occur more frequently and with greater intensity during pregnancy because of these changes. Although orgasm causes temporary uterine contractions, they are not harmful if the pregnancy has been normal. During the third trimester the missionary position maybe uncomfortable, the nurse can suggest alternate positions such as side-to-side, female-superior, and vaginal entry from the back for intercourse Couples are advised to curtail sexual activity if the women is at high risk for preterm labor. Intercourse should also be avoided if the woman has bleeding, placenta previa, ruptured membranes, or an incompetent cervix. In addition, blowing into the vagina should be avoided because it may cause an air embolus

Large and Small Intestines and Pregnancy

emptying time is decreased to allow more time for nutrient absorption

Douching

explain to the woman that douching is not necessary and it causes an increase in occurrence of bacterial vaginosis (BV) which can lead to preterm birth, premature rupture of membranes, and low birth weight

Older Children

from 3 to 12 are more aware of the changes that happen to the mother's body and might realize that a baby is to be born need preparation that mom is going to be away for a few days after birth School-age children benefit from being included in preparations for the new baby. They are interested in preparing space and supplies for the infant. They should be encouraged to feel the fetus move, and many come close to the mother's abdomen and talk to the fetus. School-age children may wonder how the birth will affect their role in the family. Parents should address these concerns and reassure the children about their continued importance. Providing books about children's experiences after the birth of a sibling may be helpful. Children as young as 3 years benefit from sibling classes. The classes provide an opportunity for them to discuss what newborns are like and what changes the new baby will bring to the family.

Travel

if driving for long periods of time, instruct her to stop every 2 hours and walk for 10 minutes to decrease chance of thrombosis air travel is generally considered safe up to 36 weeks of gestation if there are no complications, encourage her to walk frequently, and to possibly take medical records if traveling far

Maternal safety

if possible the expectant mother should adapt work schedule to include regular rest periods, and there should be no heavy lifting she should enlist the help of her support system so responsibilities at home can be reduced to promote more rest

Immunizations

immunizations with live virus vaccines are contraindicated during pregnancy, but inactivated vaccines are fine The CDC recommends that women who have not been previously vaccinated against pertussis receive the vaccine during the third or late second trimester

Development process of the expectant father

include dealing with the reality of pregnancy and the new child, working to be recognized as a parent, and making an effort to be seen as relevant to childbearing

Family's Health History

including chronic diseases such as diabetes and heart disease, and infections such as tuberculosis and hepatitis, as well as genetic and congenital anomalies

Breast care

instruct the pregnant woman to not use soap on her nipples as it removes the natural lubricant there Advise her to wear a supportive bra to prevent lose of muscle tone as breasts become heavier during pregnancy Explain that breast stimulation, which increases oxytocin secretion and may initiate uterine contractions, is unsafe if there has been a history of preterm labor or if signs of preterm labor are present.

Exposure to teratogens

intrauterine exposure to toxic substance especially during the first trimester during organogensis is particular concern advise women to evaluate occupation and home environment for any potential exposures i.e hairdressers are exposed to toxic substances in hair dyes and aerosol sprays and laundry, nail solon, and dry cleaning workers may be exposed to fetotoxic compounds. Nurses and hospital personnel may be exposed to infectious diseases, radiation, and anesthetic gases. Pesticides are another source of teratogen exposure. In addition, passive smoking is harmful to both mother and fetus.

Mimicry

involves observing and copying the behaviors of other women who are pregnant or already mothers in an attempt to discover what the role is like

Doula

is a trained labor support person who is employed by the mother to provide labor support

primipara

is a woman who has delivered one pregnancy at 20 or more weeks of gestation

multipara

is a woman who has delivered two or more pregnancies at 20 or more weeks of gestation the number of fetuses at pregnancy does not effect para

nullipara

is a woman who has never completed a pregnancy beyond 20 weeks of gestation because she has never been pregnant or has had a spontaneous or elective abortion

primigravida

is a woman who is pregnant for the first time

Fetal Movement

is not usually felt til the second trimester, most women experience subtle fetal movement or quickening between 16 and 20 weeks

Parental adaption

is often ignored by the health care team as well by his peer group some are emotionally invested and explore everything related to pregnancy, parenting etc others are task oriented and view themselves as managers or coaches to the pregnant woman

Nägele's rule

is often used to establish EDD. The method involves subtracting 3 months from the first day of the LNMP, adding 7 days, and correcting the year, if appropriate.

Relaxin

is produced by the corpus luteum, decidua, and placenta. Relaxin inhibits uterine activity, softens connective tissue in the cervix, and lengthens pubic ligaments

Amenorrhea

is the absence of menstruation.

Weight Gain

it is recommended that women with normal weight before pregnancy gain 25 to 35 pounds during pregnancy around half is from the amniotic fluid

Barriers to prenatal care

limited by financial, systemic, and attitudinal barriers An important barrier to health care results from the unsympathetic attitude of some health care workers toward those who are unable to pay for prenatal care. Nurses must treat each family with respect and consideration and must insist that poor families who are unable to pay receive the same standard of care and respect as that received by families who can pay. Scheduling prenatal visits in the evening or on weekends, setting aside times for walk-in prenatal visits, and offering other services such as Medicaid and WIC applications might increase use of prenatal services.

False positive pregnancy results

may be caused by Hematuria and proteinuria as well as Some anticonvulsants, antiparkinsonian drugs, hypnotics, and tranquilizers

False negative pregnancy results

may occur when the instructions are not followed properly, it is too early in the pregnancy, the urine is too dilute, or the woman is taking certain drugs such as diuretics

Steps in Maternal Role taking

mimicry, role play, fantasy, the search for a role fit, and grief work

seeking safe passage

must be obtained before moving on to other tasks Behaviors that ensure safe passage include seeking the care of a physician or nurse-midwife and following recommendations about diet, vitamins, rest, and subsequent visits for care. in addition the pregnant woman must adhere to cultural practices that ensure the safety of herself and the infant

Alcohol and Illegal drugs

no amount of alcohol is safe during pregnancy if expectant mother is using any illegal drugs assist her to obtain help to quit this behavior

Learning to give of herself

often idealized but is crucial for mother to do

Vaginal bleeding with or without discomfort

possible cause: Spontaneous abortion, placenta previa, abruptio placentae, lesions of the cervix or vagina, "bloody show"

continuous pounding headaches

possible cause: Chronic hypertension or preeclampsia

Persistent or severe abdominal or epigastric pain

possible cause: Ectopic pregnancy (if early), worsening preeclampsia, abruptio placentae

persistent vomiting

possible cause: Hyperemesis gravidarum

painful urination

possible cause: UTI

Convulsions

possible cause: eclampsia

Swelling of the fingers (rings become tight) or puffiness of the face or around the eyes

possible cause: excessive edema

Change in frequency or strength of fetal movements

possible cause: fetal compromise or death

chills or fever

possible cause: infection

Signs or symptoms of preterm labor: uterine contractions, cramps, constant or irregular low backache, pelvic pressure, watery vaginal dischargeSigns or symptoms of preterm labor: uterine contractions, cramps, constant or irregular low backache, pelvic pressure, watery vaginal discharge

possible cause: labor onset

escape of fluid from vagina

possible cause: rupture of membranes

Visual disturbances (such as blurred vision, dimness, flashing lights, spots before the eyes)

possible cause: worsening preeclampsia

couvade

pregnancy-related symptoms and behavior in expectant fathers

gravida

refers to a woman who is or has been pregnant regardless of the duration of the pregnancy

para

refers to the number of pregnancies that have ended at 20 or more weeks, regardless of whether the infant was born alive or was stillborn

Antepartum Assessment and Care

should begin before conception and continue during the first trimester, and continue regularly thereafter poor antepartum care is associated with low birth weight and a higher incidence of prematurity in neonates which can lead to increased infant morbidity and mortality

complementary and alternative therapies

some can be quite helpful but some such as black or blue cohosh may cause contractions or harm the fetus if used in pregnancy advice expectant mother to consult with her HCP

attachment

strong ties of attraction

Urinalysis

tested at each visit for protein, glucose, and ketones

bonding

the development of strong emotional ties with the baby this begins with quickening

Funic Souffle

the sharper whistling sound heard over the umbilical cord that corresponds to the fetal heart rate.

The fetus as the primary focus

this typically begins in the second trimester, usually feel well because the discomforts of the first trimester have passed

The self as primary focus

throughout the first trimester, the woman's focus is on herself not the fetus Nurses should concentrate on the mother's physical and psychological needs during this period of maternal self-focus. Teaching should be aimed at the common early changes of pregnancy and their normality. Morning sickness and mood swings are important subjects to explore with the couple. The nurse should assess how they are managing these changes and explain that such changes are normal and generally do not indicate problems.

Blood Volume and Pregnancy

total blood volume increases by as much as 45 percent

Ambivalene

uncertainty, many women experience ambivalence when they first learn that they are pregnant because almost half of pregnancies are unintended, therefor unexpected

Grief work

women often experience a sense of sadness when they realize that they must permanently give up certain aspects of their previous selves

Exercise

women who have no obstretic or medical problems should be instructed to exercise in moderation 30 minutes or more per day this should not be strenuous, but a continuation of normal routine recreational sports can be continued as long as there is no risk for falling or abdominal trauma

Morning sickness needs to be differentiated from hyperemesis gravidarum

—severe vomiting accompanied by weight loss, dehydration, electrolyte imbalance, and ketosis

How to overcome hemorrhoids

• Avoid constipation to prevent straining that causes or worsens hemorrhoids. Drink plenty of water, eat foods rich in fiber, and exercise regularly. • To relieve existing hemorrhoidal discomfort, take frequent, tepid baths. Apply cool witch hazel compresses or anesthetic ointments. • Lie on your side with the hips elevated on a pillow. • If pain persists or bleeding occurs, call your health care provider.

How to overcome varicosities

• Avoid constricting clothing and crossing the legs at the knees, which impedes blood return from the legs. • Rest frequently with the legs elevated above the level of the hips. • Wear support hose or elastic stockings that reach above the varicosities. Apply them before getting out of bed each morning. • If working in one position for prolonged periods, walk around for a few minutes at least every 2 hours.

How to overcome urinary frequency

• Decrease fluids in the evening but drink adequate amounts during the day. • Avoid caffeine, which is a natural diuretic. • Perform Kegel exercises to help maintain bladder control: Identify the muscles to be exercised by stopping the flow of urine midstream. Do not routinely perform the exercise while urinating because urinary retention may occur and increase the risk of urinary tract infection. Slowly contract the muscles around the vagina, and hold for 10 seconds. Relax at least 10 seconds. Repeat the contraction-relaxation cycle 30 times per day.

Evaluation

• Does the family verbalize concerns and emotions at each visit? • Do the partner and significant family members appear interested and involved? • Are they making appropriate progress in meeting the tasks of pregnancy? • Do the family members discuss compromises when cultural health practices are harmful?

How to overcome nausea and vomiting

• Eat dry crackers or toast before arising in the morning; then get out of bed slowly. • Eat small amounts of carbohydrate and protein foods every 2 to 3 hours and a total of 5 or 6 small meals. • Drink fluids separately from meals. Try small amounts of ice chips, water, and clear liquids like gelatin or Popsicles. Avoid coffee. • Avoid fried, greasy, fatty, or spicy foods or those with strong odors. Instead try bland foods, which may be more easily tolerated. • Try foods containing ginger or peppermint, or combine salty and tart foods like potato chips and lemonade. • Increase protein intake and eat a protein snack before bedtime. • Take prenatal vitamins at bedtime because they may increase nausea if taken in the morning. • Rest more frequently and take naps, if possible. • Use an acupressure band that applies pressure over a point approximately three fingerbreadths above the wrist crease on the inner arm. • Ask your health care provider if vitamin B6 (pyridoxine) would be helpful. • Check with your primary caregiver before taking any herbal remedies. • Notify your health care provider for severe nausea and vomiting or signs of dehydration (dry, cracked lips; elevated pulse; fever; concentrated urine).

How to overcome heartburn

• Eat small meals every 2 to 3 hours, and avoid fatty, acidic, or spicy foods. • Eliminate or curtail smoking and drinking coffee and carbonated beverages, which stimulate acid formation in the stomach. • Try chewing gum. • Take a tablespoon of cream before meals if heartburn is not already present. • Do not eat or drink just before bedtime, and sleep with an extra pillow. • Walk or sit upright for 1 to 2 hours after meals to reduce reflux and relieve symptoms. • Avoid bending over. • Wear loose-fitting clothes. • Take deep breaths and sip water to help relieve the burning sensation. • Use only antacids suggested by your care provider, but avoid those that are high in sodium (Alka-Seltzer, baking soda), which cause fluid retention. Antacids high in calcium (Tums, Alka-Mints) provide relief but may cause rebound hyperacidity. Liquid antacids may be more effective.

Obstetric History

• Gravidity, parity, abortions, and living children • Weight of infants at birth, length of gestations • Labor experiences, type of deliveries, locations of births, names of physicians or midwives • Types of anesthesia and any difficulties with anesthesia during childbirth or previous surgeries • Maternal complications, such as hypertension, diabetes, infection, or bleeding • Infant complications • Methods of infant feeding used in the past and currently planned • Special concerns

How to overcome backache

• Maintain correct posture: head up, shoulders back. • Do not gain excess weight. • Avoid high-heeled shoes because they increase lordosis. • To pick up objects, squat rather than bend at the waist. • Do not lift heavy objects. • When sitting, use foot supports, arm rests, and pillows behind the back. • Perform exercises such as tailor sitting, shoulder circling, and pelvic rocking, which strengthen the back and prepare for labor.

How to overcome leg cramps

• To prevent cramps, elevate the legs often during the day to improve circulation. • To relieve cramps, extend the affected leg, keeping the knee straight. Bend the foot toward the body, or ask someone to assist. If alone, stand and apply pressure on the affected leg with the knee straight. • Avoid excessive foods high in phosphorus. Check with your health care provider about taking additional calcium or magnesium.

How to overcome round ligament pain

• Use good body mechanics, and avoid strenuous exercise. • Do not make sudden movements or position changes. • Avoid stretching and twisting at the same time. When getting out of bed, turn to the side without twisting and then get up slowly. • Bend toward the pain, squat, or bring the knees up to the chest to relieve pain by relaxing the ligament. • Apply heat and lie on the right side to relieve the pain.

Box 13-2 Birth Plan Conisderations

• Use of intermittent or continuous fetal monitoring • Intravenous fluids: use, avoidance, saline lock • Food and oral fluids allowed in labor • Position and activity for labor, position for delivery • Use of tubs, showers, birthing balls • Episiotomy • Methods of pain relief • Support persons present during labor • Medical interventions (such as induction of labor) • Breastfeeding only, formula only, combination feeding • Participation of siblings during/after birth • Mother/baby couplet care • Time of discharge

How to overcome consitpation

• Use self-care measures that generally are as effective as using laxatives, but do not interfere with absorption of nutrients or lead to laxative dependency. • Drink at least eight glasses of liquids including water, juice, or milk each day. These should not include coffee, tea, or carbonated drinks because of their diuretic effect. After drinking diuretic beverages, add a glass of water. • Add foods high in fiber such as unpeeled fresh fruits and vegetables, whole-grain bread or cereals, bran muffins, oatmeal, baked potatoes with skins, dried beans, and fruit juices. Four pieces of fruit plus a large salad provide enough fiber for 1 day. • Restrict cheese consumption, which causes constipation. • Reduce intake of sweets, which increase bacterial growth in the intestine and can lead to flatulence. • Do not discontinue taking iron supplements if they have been prescribed. If constipation persists, consult your health care provider for advice about stool softeners. • Try swimming, riding a stationary bicycle, or taking a brisk walk of at least 1 mile per day to stimulate peristalsis and improve muscle tone. • Establish a regular pattern by allowing a consistent time each day for elimination. One hour after meals is ideal to take advantage of the gastrocolic reflex (the peristaltic wave in the colon that is induced by taking food into the fasting stomach). • Use a footrest or place your feet on a folded towel during elimination to provide comfort and decrease straining.

Medical & Surgical History

•Age, race, ethnic background (risk for specific genetic problems, such as sickle cell disease, thalassemia, cystic fibrosis, and Tay-Sachs disease) •Childhood diseases and immunizations •Chronic illnesses, such as asthma, heart disease, hypertension, diabetes, lupus, renal disease •Previous illnesses, surgical procedures, injuries •Previous infections such as hepatitis and tuberculosis •History of anemia •Bladder, bowel function (problems or changes) •Amount of caffeine and alcohol consumed each day •Tobacco use (number of years and number of packs per day) •Prescription, over-the-counter, or illicit drugs •Complementary or alternative therapies •General nutrition, history of eating disorders •Contact with pets, particularly cats (increased risk of infections such as toxoplasmosis) •Allergies and drug sensitivities •Occupation and related risk factors

Five major changes in blood flow during pregnancy

•Blood flow is altered to include the uteroplacental unit. •More blood must circulate through the maternal kidneys to remove the increased metabolic wastes generated by the mother and fetus. •The woman's skin requires increased circulation to dissipate the heat generated by increased metabolism during pregnancy. •Blood flow to the breasts increases resulting in engorgement and dilated veins with a feeling of heat and tingling. •The weight of the expanding uterus on the inferior vena cava and iliac veins partially obstructs blood return from veins in the legs, causing stasis of blood and venous distention. Prolonged engorgement of the veins of the lower legs may result in varicose veins of the legs, vulva, or rectum (hemorrhoids).

Cultural Assessment questions

•How will you and your family prepare for the baby? •What concerns do you have about the pregnancy? •What would provide the greatest assistance? •Where do you obtain most health care information?