1. Pregnancy



Pregnancy


Prenatal Period


The prenatal period is a time of physical and psychologic preparation for birth and parenthood.



Diagnosis of Pregnancy




Estimating Date of Birth



Gravidity and Parity


Box 1-2 defines terms related to gravidity and parity.



NURSING ALERT


Information related to obstetrics may be noted in a woman’s records in a variety of ways because no one standardized system exists. Until such a system is in place, the nurse should understand the documentation system used by the health care facility.



ent Gravidity and parity may be described with only two digits: The first digit represents the number of pregnancies the woman has had, including the present one, and parity is the number of pregnancies that have reached 20 or more weeks of gestation. For example, if the woman had twins at 36 weeks with her first pregnancy, parity would still be counted as one birth (gravida 1, para 1).


ent Another system which is commonly used consists of five digits separated by hyphens to describe obstetric history: gravidity—number of term births—number of preterm births—number of abortions (miscarriage or elective termination of pregnancy)—number of children currently living.


ent The acronym GTPAL (gravidity, term, preterm, abortions, living children) may be helpful in remembering this system of notation.


ent For example, if a woman pregnant only once gives birth at week 34 and the infant survives, the abbreviation that represents this information is “1-0-1-0-1.” During her next pregnancy, the abbreviation is “2-0-1-0-1.”



BOX 1-2


Definitions Related to Gravidity and Parity



ent Gravida: a woman who is pregnant


ent Gravidity: pregnancy


ent Late preterm: a pregnancy that ends between 34 and 36 6/7 wk of gestation


ent Multigravida: a woman who has had two or more pregnancies


ent Multipara: a woman who has completed two or more pregnancies to 20 or more wk of gestation


ent Nulligravida: a woman who has never been pregnant


ent Nullipara: a woman who has not completed a pregnancy with a fetus or fetuses who have reached 20 wk of gestation


ent Parity: the number of pregnancies in which the fetus or fetuses have reached 20 wk of gestation when they are born, not the number of fetuses (e.g., twins) born. Whether the fetus is born alive or is stillborn (fetus who shows no signs of life at birth) does not affect parity.


ent Postdate or postterm: a pregnancy that goes beyond 42 wk of gestation


ent Preterm: a pregnancy that has reached 20 wk of gestation but ends before completion of 37 wk of gestation


ent Primigravida: a woman who is pregnant for the first time


ent Primipara: a woman who has completed one pregnancy with a fetus or fetuses who have reached 20 wk of gestation


ent Term: a pregnancy from the completion of wk 37 of gestation to the end of wk 42 of gestation


ent Viability: capacity to live outside the uterus; there are no clear limits of gestational age or weight but it is rare for a fetus to survive before 22 to 24 wk of gestation and weighing less than 500 g


Sources: Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Rouse, D., & Spong, C. (2010). Williams obstetrics (23rd ed.). New York: McGraw-Hill; Katz, V. (2007). Spontaneous and recurrent abortions. In V. Katz, G. Lentz, R. Lobo, & D. Gershenson (Eds.), Comprehensive gynecology (5th ed.). Philadelphia: Mosby.


Adaptation to Pregnancy


Pregnancy affects all family members; each member must adapt to the pregnancy and interpret its meaning in light of his or her own needs.


The following descriptions are based on the traditional North American model and may not apply to families who do not fit that model.



ent Women of all ages use the months of pregnancy to adapt to the maternal role, a complex process of social and cognitive learning.


ent Developmental tasks of the mother include 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.


ent Mood swings, irritability, and ambivalence about the pregnancy are normal responses in early pregnancy whether the pregnancy was planned or not.


ent 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.


ent Emotional attachment begins during the prenatal period as women use fantasizing and daydreaming to prepare for motherhood. The mother-child relationship progresses through pregnancy.


ent Many women actively prepare for birth by reading books, viewing films, attending parenting classes, and talking to other women.


ent Toward the end of the third trimester, most women become impatient for labor to begin, whether the birth is anticipated with joy, dread, or both. They have a strong desire to see the end of pregnancy.


ent The sexual relationship is affected by physical, emotional, and interactional factors, including myths about sex during pregnancy, sexual dysfunction, and physical changes in the woman.


ent Developmental tasks experienced by the expectant father include acknowledgment of the biologic fact of pregnancy, adjustment to the reality of pregnancy, and acceptance of the pregnancy. In the last trimester the father becomes actively involved in both the pregnancy and his relationship with his child. He begins to think of himself as a father.


ent Some men experience pregnancy-like symptoms, such as nausea, weight gain, and other physical symptoms. This phenomenon is known as the couvade syndrome.


ent As the expected date of birth approaches, many men experience anticipation and anxiety. Major concerns are getting the woman to a health care facility in time for the birth and not appearing ignorant. The man also may have fears concerning safe passage of his child and partner and the possible death or complications of his partner and child.


ent Parents may occasionally show or voice disappointment over the gender of the child. Negative responses are usually temporary.


ent Siblings’ responses to pregnancy vary with their age and dependency needs.


ent The 1-year-old infant seems largely unaware of the process.


ent Toddlers may exhibit more clinging behavior and revert to dependent behaviors in toilet training or eating.


ent By age 3 or 4 years, children like to be told the story of their own beginning and accept its being compared with the present pregnancy. They like to listen to the fetal heartbeat and feel the baby moving in utero.


ent School-age children take a more clinical interest in their mother’s pregnancy. They may want to know in more detail, “How did the baby get in there?” and “How will it get out?”


ent 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.


ent Late adolescents do not appear to be unduly disturbed. They are busy making plans for their own lives.


ent Box 1-3 lists suggestions for sibling preparation.


ent Most grandparents are delighted at the prospect of a new baby in the family. The grandparents’ presence and support can strengthen family systems by widening the circle of support and nurturance.


ent Grandparents may need information about changes in maternity care and childbirth practices that have occurred since they had their children.




BOX 1-3


Tips for Sibling Preparation


Prenatal



During the Hospital Stay



Going Home



Adjustment after the Baby is Home



Care Management


The purpose of prenatal care is to identify existing risk factors and other deviations from normal so that pregnancy outcomes can be enhanced. Major emphasis is placed on preventive aspects of care.


Prenatal Visit Schedule



ent In traditional prenatal care 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. Research supports a model of fewer prenatal visits, and in some practices there is a growing tendency to have fewer visits with women who are at low risk for complications.


ent CenteringPregnancy, a care model that is gaining in popularity, is group prenatal care in which authority is shifted from the provider to the woman and other women who have similar due dates. Most care takes place in the group setting after the first visit. At each meeting the first 30 minutes is spent in completing assessments (by the woman and by the health care provider), and the rest of the time is spent in group discussion of specific issues such as discomforts of pregnancy and preparation for labor and birth. Families and partners are encouraged to participate.


ent In CenteringPregnancy, the first visit is scheduled within the first trimester (12 weeks). Thereafter, women are seen every 4 weeks from week 16 to week 28 and every 2 weeks during weeks 29 through 40.


Initial Visit



ent 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.


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


ent Childbearing and female reproductive system history. The woman’s age at menarche, menstrual history, and contraceptive history; the nature of any infertility or gynecologic conditions; sexually transmitted infections (STIs); sexual history; and details of all her pregnancies, including the present pregnancy, and their outcomes. Date of the last Papanicolaou (Pap) test and the result. Date of her LMP to establish the EDB.


ent Medical history. Physical conditions or surgical procedures that can affect the pregnancy or that can be affected by the pregnancy. Description of the nature of previous surgical procedures, especially reproductive ones. Presence of any handicapping conditions.


ent Nutritional history. A dietary assessment to identify special dietary practices, food allergies, eating behaviors, the practice of pica, and other factors related to her nutritional status.


ent History of drug and herbal preparations use. Past and present use of legal (over-the-counter [OTC] and prescription medications; herbal preparations; caffeine; alcohol; nicotine) and illegal (e.g., marijuana, cocaine, heroin) drugs. Informed consent must be obtained before testing for drug use.


ent Family history. Information about familial or genetic disorders or conditions that could affect the present health status of the woman or her fetus.


ent Social, experiential, and occupational history. Situational factors, such as the family’s ethnic and cultural background and socioeconomic status. Woman’s past and present work settings.


ent History or risk of physical abuse. The likelihood of abuse by the partner increases during pregnancy; sexual assault by the partner is common. Assess for reports of physical blows directed to the head, breasts, abdomen, and genitalia.


ent Review of systems. Identify and describe preexisting or concurrent problems in any of the body systems; assess her mental status. For each sign or symptom described, obtain the following data: body location, quality, quantity, chronology, aggravating or alleviating factors, and associated manifestations (onset, character, course).


ent Physical examination. Record vital signs and height and weight. Each examiner develops a routine for proceeding with the physical examination; most choose the head-to-toe progression.


ent One vaginal examination during pregnancy is recommended; others are done if medically indicated.


ent Laboratory tests. Tests are listed in Table 1-1.



TABLE 1-1


Laboratory Tests in the Prenatal Period























































Laboratory Test Purpose
Hemoglobin, hematocrit, WBC, differential Detects anemia; detects infection
Hemoglobin electrophoresis Identifies women with hemoglobinopathies (e.g., sickle cell anemia, thalassemia)
Blood type, Rh, and irregular antibody Identifies those fetuses at risk for developing erythroblastosis fetalis or hyperbilirubinemia in neonatal period
Rubella titer Determines immunity to rubella
Tuberculin skin testing; chest film after 20 wk of gestation in women with reactive tuberculin tests Screens for exposure to tuberculosis
Urinalysis, including microscopic examination of urinary sediment; pH, specific gravity, color, glucose, albumin, protein, RBCs, WBCs, casts, acetone; hCG Identifies women with glycosuria, renal disease, hypertensive disease of pregnancy; infection; occult hematuria
Urine culture Identifies women with asymptomatic bacteriuria
Renal function tests: BUN, creatinine, electrolytes, creatinine clearance, total protein excretion Evaluates level of possible renal compromise in women with a history of diabetes, hypertension, or renal disease
Pap test Screens for cervical intraepithelial neoplasia; if a liquid-based test is used, may also screen for HPV
Cervical culture for Neisseria gonorrhoeae, Chlamydia Screens for asymptomatic infection in high risk women
Rectovaginal culture Screens for GBS infection; done at 35-37 wk
RPR, VDRL, or FTA-ABS Identifies women with untreated syphilis
HIV antibody,∗ hepatitis B surface antigen, toxoplasmosis
MSAFP/Quad Screen		 Screens for specific infections
Screens for NTDs, Down syndrome; performed at 15-20 wks (16-18 wks is ideal)
1-hr glucose tolerance Screens for gestational diabetes; done at initial visit for women with risk factors; done at 24-28 wk for at risk pregnant women who tested negative at the initial screening; women who are low risk by history and clinical risk factors are usually not screened
3-hr glucose tolerance Diagnoses gestational diabetes in women with elevated glucose level after 1-hr screen; must have two elevated readings for diagnosis
Cardiac evaluation: ECG, chest x-ray film, and echocardiogram Evaluates cardiac function in women with a history of hypertension or cardiac disease

BUN, Blood urea nitrogen; ECG, electrocardiogram; FTA-ABS, fluorescent treponemal antibody absorption test; GBS, group B streptococci; hCG, human chorionic gonadotropin; HIV, human immunodeficiency virus; HPV, human papillomavirus; MSAFP, maternal serum alpha-fetoprotein; NTD, neural tube defects; RBC, red blood cell; RPR, rapid plasma reagin; VDRL, Venereal Disease Research Laboratory; WBC, white blood cell.


∗Universal opt-out screening is recommended for HIV.


Follow-up Visits



ent The pattern of interviewing the woman first and then assessing physical changes and performing laboratory tests is maintained.


ent At each visit the woman is asked to summarize relevant events that have occurred since the previous visit. She is asked about her general emotional and physiologic well-being, complaints, problems, and questions she may have. Personal and family needs are identified and explored. The woman’s physical systems are reviewed. Any suspicious signs or symptoms are assessed in depth.


ent At each visit, physical parameters are measured.


ent Take the blood pressure using the same arm at every visit, with the woman sitting, using a cuff of appropriate size.


ent Weight: Note the appropriateness of the gestational weight gain in relation to her body mass index (BMI).


ent Note the location and degree of edema.


ent Examination of the abdomen: The woman lies on her back with her arms by her side and head supported by a pillow. The bladder should be empty. Abdominal inspection is followed by measurement of the height of the fundus.



NURSING ALERT


Be alert for supine hypotension. When a woman is lying on her back, the weight of the abdominal contents may compress the vena cava and aorta, causing a decrease in blood pressure and a feeling of faintness. If this occurs, turn the woman onto her side until her symptoms are gone and her vital signs stabilize.



ent Monitor for a range of signs and symptoms that indicate potential complications in addition to hypertension. (See the Signs of Potential Complications box.)


ent Assess fetal heart tones (FHTs) at each visit usually beginning toward the end of the first trimester when they can be heard with an ultrasound fetoscope or an ultrasound stethoscope.


ent The fundal height, 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. From approximately 18 to 32 weeks of gestation with an empty bladder at the time of measurement, the height of the fundus in centimeters is approximately the same as the number of weeks of gestation (±2).


ent A stable or decreased fundal height may indicate intrauterine growth restriction (IUGR).


ent An excessive increase could indicate a multifetal gestation (more than one fetus) or hydramnios.





ent Fetal gestational age is determined from the menstrual history, contraceptive history, pregnancy test result, and the following findings obtained during the clinical evaluation:


ent First uterine evaluation: date, size


ent Fetal heart (FH) first heard: date, method (Doppler stethoscope, fetoscope)


ent Date of quickening


ent Current fundal height, estimated fetal weight (EFW)


ent Current week of gestation by history of LMP and/or ultrasound examination


ent Ultrasound examination: date, week of gestation, biparietal diameter (BPD)


ent Reliability of dates


ent Quickening (“feeling of life”), the mother’s first perception of fetal movement, usually occurs between weeks 16 and 20 of gestation. Multiparas often perceive fetal movement sooner than primigravidas, as early as 14 weeks.


ent Ultrasound examination in early pregnancy may be used to establish the duration of pregnancy if the woman cannot give a precise date for her LMP or if the size of the uterus does not conform to the EDB as calculated by Nägele’s rule. Ultrasound also provides information about the well-being of the fetus. The use of ultrasound has become routine in the United States.


ent Regular fetal movement is a reliable indicator of fetal health. The mother is instructed to note the extent and timing of fetal movements and to report immediately if the pattern changes or if movement ceases.


Laboratory Tests


See Table 1-1 for diagnostic tests used to assess the health status of both the pregnant woman and the fetus.


Interventions


Education About Maternal and Fetal Changes

Expectant parents are typically curious about the growth and development of the fetus and the subsequent changes that occur in the mother’s body. Mothers are sometimes more tolerant of the discomforts related to the continuing pregnancy if they understand the underlying causes. Educational literature that describes fetal and maternal changes can be used to explain changes as they occur. Educational material may include electronic and written materials appropriate to the pregnant woman’s or couple’s literacy level and experience and the agency’s resources. To be most effective, it is important that these materials reflect the pregnant woman’s or couple’s ethnicity, culture, and literacy level.


Teaching for Self-Management

The expectant mother needs information about many subjects. Several topics that may cause concerns are discussed in the following sections.



ent Nutrition. Teaching may include discussion about foods high in iron, those that contain folic acid, and the importance of taking prenatal vitamins, limiting caffeine intake, and avoiding drinking alcohol.


ent Refer women to a registered dietitian if a need for in-depth counseling is identified.


ent Personal hygiene. During pregnancy the sebaceous (sweat) glands are highly active because of hormonal influences, and women often perspire freely.


ent Baths and warm showers can be therapeutic because they relax tense, tired muscles; help counter insomnia; and make the pregnant woman feel fresh.


ent Tub bathing is permitted even in late pregnancy because little water enters the vagina unless under pressure. However, late in pregnancy, when the woman’s center of gravity lowers, she is at risk for falling.


ent Tub bathing is contraindicated after rupture of the membranes.


ent Preventing urinary tract infections. Instruct women to inform their health care provider if blood or pain occurs with urination. Instruct in the following preventive measures:


ent Use good handwashing techniques before and after urinating; wipe the perineum from front to back. Use soft, absorbent toilet tissue, preferably white and unscented; harsh, scented, or printed toilet paper may cause irritation.


ent Avoid using bubble bath or other bath oils because these may irritate the urethra.


ent Wear cotton crotch underpants and pantyhose and avoid wearing tight-fitting slacks or jeans for long periods; anything that allows a buildup of heat and moisture in the genital area may foster the growth of bacteria.


ent Advise the woman to drink at least 2 L (eight glasses) of liquid, preferably water, each day to maintain an adequate fluid intake that ensures frequent urination.


ent Pregnant women should not limit fluids in an effort to reduce the frequency of urination.


ent Inform women that if the urine looks dark (concentrated), they must increase their fluid intake.


ent Consuming yogurt and acidophilus milk may help prevent urinary tract and vaginal infections.


ent Review healthy urination practices with the woman.


ent Do not ignore the urge to urinate, because holding urine lengthens the time bacteria are in the bladder and allows them to multiply.


ent Always urinate before going to bed at night.


ent Because bacteria can be introduced during intercourse, urinate before and after intercourse, and then drink a large glass of water to promote additional urination.


ent Preparing for breastfeeding. A woman’s decision about the method of infant feeding often is made before pregnancy. The pregnant woman is encouraged to breastfeed. Support for the woman and her partner should be provided, whichever method of feeding is selected.


ent Women with inverted nipples need special consideration if they are planning to breastfeed. The pinch test is done to determine whether the nipple is everted or inverted.


ent To perform the pinch test, have the woman place her thumb and forefinger on her areola and gently press inward. The nipple will either stand erect or invert. Most nipples will stand erect.


ent Breast shells, small plastic devices that fit over the nipples, may be recommended for women who have flat or inverted nipples. Breast shells should be worn for 1 to 2 hours daily during the last trimester of pregnancy, for gradually increasing periods of time.


ent Teach the woman to cleanse the nipples with warm water to keep the ducts from being blocked with dried colostrum. Soap, ointments, alcohol, and tinctures should not be applied because they remove protective oils that keep the nipples supple and prevent cracking of the nipples during early lactation.


ent Dental care. Dental care during pregnancy is especially important because nausea during pregnancy may lead to poor oral hygiene, allowing dental caries to develop. A fluoride toothpaste should be used daily. Dental surgery is not contraindicated during pregnancy. If dental treatment is necessary, the woman will be most comfortable having it done during the second trimester because the uterus is outside the pelvis but not so large as to cause discomfort while she sits in a dental chair.


ent Physical activity. See the Teaching for Self-Management box: Exercise Tips for Pregnant Women.




Teaching for Self-Management


Exercise Tips for Pregnant Women



ent Consult your health care provider when you know or suspect you are pregnant. Discuss your health and pregnancy history, your current exercise regimen, and the exercises you would like to continue throughout pregnancy.


ent Seek help in determining an exercise routine that is well within your limit of tolerance, especially if you have not been exercising regularly.


ent Consider decreasing weight-bearing exercises (jogging, running) and concentrating on non–​weight-bearing activities such as swimming, cycling, or stretching. If you are a runner, starting in your seventh month, it is advisable to walk instead.


ent Avoid risky activities such as surfing, mountain climbing, skydiving, and racquetball because such activities, which require precise balance and coordination, may be dangerous. Avoid activities that require holding your breath and bearing down (Valsalva maneuver). Jerky, bouncy motions also should be avoided.


ent Exercise regularly every day if possible, as long as you are healthy, to improve muscle tone and increase or maintain your stamina. Exercising sporadically may put undue strain on your muscles.


ent Thirty minutes of moderate physical exercise is recommended. This activity can be broken up into shorter segments with rest in between. For example, exercise for 10 to 15 min, rest for 2 to 3 min, then exercise for another 10 to 15 min.


ent Decrease your exercise level as your pregnancy progresses. The normal alterations of advancing pregnancy, such as decreased cardiac reserve and increased respiratory effort, may produce physiologic stress if you exercise strenuously for a long time.


ent Take your pulse every 10 to 15 min while you are exercising. If it is more than 140 beats/min, slow down until it returns to a maximum of 90 beats/min. You should be able to converse easily while exercising. If you cannot, you need to slow down.


ent Avoid becoming overheated for extended periods. It is best not to exercise for more than 35 min, especially in hot, humid weather. As your body temperature rises, the heat is transmitted to your fetus. Prolonged or repeated elevation of fetal temperature may result in birth defects, especially during the first 3 mo. Your temperature should not exceed 38° C.


ent Avoid the use of hot tubs and saunas.


ent Warm-up and stretching exercises prepare your joints for more strenuous exercise and lessen the likelihood of strain or injury to your joints. After the fourth month of gestation you should not perform exercises flat on your back.


ent A cool-down period of mild activity involving your legs after an exercise period will help bring your respiration, heart, and metabolic rates back to normal and prevent the pooling of blood in the exercised muscles.


ent Rest for 10 min after exercising, lying on your side. As the uterus grows, it puts pressure on the vena cava, a major vein in your abdomen, which carries blood to your heart. Lying on your side removes the pressure and promotes return circulation from your extremities and muscles to your heart, thereby increasing blood flow to your placenta and fetus. You should rise gradually from the floor to prevent dizziness or fainting (orthostatic hypotension).


ent Drink two or three 8-oz glasses of water after you exercise to replace the body fluids lost through perspiration. While exercising, drink water whenever you feel thirsty.


ent Increase your caloric intake to replace the calories burned during exercise and provide the extra energy needs of pregnancy. (Pregnancy alone requires an additional 340-452 kcal/day.) Choose high-protein foods such as fish, milk, cheese, eggs, and meat.


ent Take your time. This is not the time to be competitive or train for activities requiring speed or long endurance.


ent Wear a supportive bra. Your increased breast weight may cause changes in posture and put pressure on the ulnar nerve.


ent Wear supportive shoes. As your uterus grows, your center of gravity shifts and you compensate for this by arching your back. These natural changes may make you feel off balance and more likely to fall.


ent Stop exercising immediately if you experience shortness of breath, dizziness, numbness, tingling, pain of any kind, more than four uterine contractions per hour, decreased fetal activity, or vaginal bleeding, and consult your health care provider.

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Related posts:

  1. 8. Selected Newborn Complications
  2. 7. The Newborn
  3. 6. Selected Postpartum Complications
  4. 2. Selected Pregnancy Complications

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Jul 18, 2016 | Posted by in NURSING | Comments Off on 1. Pregnancy

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