Preconception care is health care and screening conducted before pregnancy occurs so that medical risk factors or lifestyle behaviors can be identified, managed, or changed before conception. The normalcy of pregnancy is greatly influenced by prepregnancy health. Most women who seek medical care as soon as they realize they may be pregnant are already at or past 8 weeks’ gestation, which may be too late for some interventions to be effective. Most birth defects occur between 2 and 8 weeks’ gestation. These missed opportunities include ensuring an adequate daily intake of folic acid, updating immunization status, ceasing smoking, treating current infections, and obtaining genetic counseling or testing. Prenatal data collection includes physical, psychological, and psychosocial factors that will affect the health of the mother and fetus. This includes exposure to hazardous materials in the workplace. Ideally, prenatal care starts before pregnancy occurs. Preconception care is best achieved when a pregnancy is planned.

Early and regular prenatal care dramatically reduces infant and maternal morbidity and mortality and offers a unique opportunity for nurses to influence the family’s health. Early detection of potential problems leads to prompt assessment and treatment, which greatly improves the pregnancy outcome. Pregnancy is a normal process, and the primary focus is education for self-care. Pregnancy affects the mother’s body and the family’s integrity; therefore, the entire family is included in the care plan (Figure 5-1). The major goals of prenatal care are listed in Box 5-1.

Cultural competence is the awareness of, acceptance of, and respect for beliefs, values, traditions, and practices that are different from one’s own. The ability to adapt health care so that it does not violate the culture or religion of the patient is the core of cultural competence. Achieving cultural competence is aided by knowledge, skills, and encounters with others of different cultures. The assumption that all people of one culture believe and behave the same way is cultural stereotyping and should be avoided. Individual differences should be identified and respected (Figure 5-2). For example, in some cultures, such as Orthodox Judaism, the husband may not view the newborn as it is delivered; only verbal encouragement is allowed. Many non-Western cultures expect the woman to have 40 days of rest after delivery. Chinese, African American, Hispanic, and Southeast Asian cultures usually avoid full washing of the body and hair until lochia has ceased. The “hot and cold” theory is observed by many cultures, and, because labor and delivery are considered a “cold” experience, it is balanced by “hot” conditions; therefore, ice water and air-conditioning are avoided. Cambodian women often discard colostrum. In the traditional Japanese culture, newborns are bathed twice a day, and the bathing is accompanied by loud noises to ward off evil spirits.

High-risk pregnancies are those in which maternal and fetal outcomes are potentially not as good as in a normal pregnancy. The improved understanding of fetal disorders and extraordinary technical advances are changing the management of high-risk pregnancies. Newer diagnostic and therapeutic approaches are being used in the management of complex problems. High-risk pregnancy presents one of the most critical challenges in medical and nursing care. Emphasis must be placed on the safe birth of infants who can develop to their maximum potential (Box 5-2).

This section discusses a range of technologies and procedures designed to reduce risks to the woman and the fetus. These procedures include nursing responsibilities that must be carried out to provide safe care, reduce risks, and meet emotional needs. See Chapter 13 for detailed information concerning complications of pregnancy.

Diagnostic Techniques and Nursing Considerations

A variety of tests can be used to assess fetal well-being during pregnancy and are indicated when maternal high-risk factors are present (Table 5-2). These tests include diagnostic ultrasound, Doppler ultrasound blood flow, chorionic villi sampling, amniocentesis, percutaneous cord blood sampling, nonstress test (NST), contraction stress test (CST), biophysical profile (BPP), vibroacoustic stimulation test, and maternal assessment of fetal movements (Figures 5-4 to 5-6 on p. 69).

Table 5-2

Tests to Assess Fetal Well-Being

Test and Description	Major Uses During Pregnancy
Ultrasound imaging: High-frequency waves are used to visualize internal organs or tissues within the body (e.g., fetus, placenta, or moving object such as a beating fetal heart); also called ultrasonography; a transvaginal probe or abdominal transducer is used. Abdominal ultrasound requires a full bladder for better visualization (have the woman drink 1-2 qt of water before the examination). Procedure is noninvasive, is painless, and lasts approximately 20 minutes.	Confirms the pregnancy Confirms gestational age Identifies site of implantation (uterine or ectopic) Verifies fetal viability or death Identifies multifetal pregnancy (e.g., twins) Rules out specific fetal abnormalities Evaluates vaginal bleeding and location of placenta Determines amniotic fluid volume Observes fetal movements (fetal heartbeat, breathing, activity, and body movements) Used to guide procedures such as amniocentesis and chorionic villus sampling
Doppler ultrasound blood flow: Method of noninvasively studying blood flow in maternal and fetal circulations; a hand-held ultrasound device is used. Echo Doppler scan detects fetal heart activity at 6-10 weeks’ gestation.	Assesses maternal-fetal blood flow Detects fetal anemia in Rh isoimmunization May identify intrauterine growth restriction (IUGR) and placental insufficiency Color Doppler imaging views heart and blood vessel structure and can detect anomalies in vessels within the umbilical cord
Chorionic villus sampling: A first-trimester alternative to amniocentesis for prenatal diagnosis of some conditions; small amount of the developing placenta (chorionic villi) is aspirated by syringe under the guidance of ultrasound and analyzed. Performed at 10-12 weeks’ gestation.	Recommended only for women at risk for giving birth to baby with a genetic chromosomal or metabolic abnormality (cannot be used to determine spina bifida or anencephaly) Results of chromosome studies available in 24-48 hours Risk of abortion higher than in amniocentesis; potential limb reduction defect in fetus Rho(D) immune globulin (RhoGAM) is given to Rh-negative women Can be done earlier in gestation
Amniocentesis: Performed to obtain amniotic fluid–containing fetal cells; under direct visualization of ultrasound, a thin needle is inserted through the abdominal and uterine walls to withdraw amniotic fluid into a syringe (with cast-off cells). Sufficient fluid must be present for the test to be done (15-17 weeks’ gestation and 12-14 weeks’ gestation for some disorders).	Early pregnancy Used to assess genetic disorders (e.g., Tay-Sachs disease) Tests for level of alpha-fetoprotein (AFP), which is also present in maternal blood High AFP levels found in neural tube defects such as spina bifida (open spine) or anencephaly (incomplete development of skull and brain) Low levels of AFP associated with chromosomal disorders or gestational trophoblastic disease Late pregnancy Assesses for severity of maternal-fetal blood incompatibility and fetal lung maturity; RhoGAM given to Rh-negative women Minimal risk for abortion in late pregnancy but higher in early pregnancy Safety concerns: risk of infection, pregnancy loss (although slight), and needle injuries to fetus or placenta
Tests for fetal lung maturity: Amniotic fluid obtained by amniocentesis is tested to indicate if fetal lungs are mature enough to adapt to extrauterine life. Lecithin/sphingomyelin (L/S) ratio: a 2:1 ratio indicates fetal lung maturity (3:1 ratio is desirable for diabetic mother) Presence of phosphatidylglycerol (PG) Foam stability index (FSI, or “shake test”): if ring of bubbles persists for 15 minutes after shaking solution, test is termed positive and indicates surfactant is present and fetal lungs are mature.	Determines whether the fetus is likely to have respiratory distress in adapting to extrauterine life Sometimes used to determine whether the fetal lungs are mature enough before cesarean birth Also evaluates whether the fetus should be removed immediately or whether the lungs should be allowed to develop more in utero after the membranes have ruptured and gestation is <37 weeks (or date is questionable) Absence of PG associated with respiratory distress Blood or meconium in the amniotic fluid alters accuracy of results
Percutaneous umbilical blood sampling (cordocentesis): Obtaining fetal blood sample from placental vessel or from the umbilical cord by guidance with ultrasound (see Figure 5-6).	Evaluates whether the fetus is anemic and needs a blood transfusion. Identifies Rh isoimmunization in the blood and chromosomal disorders and acid-base status of fetus
Nonstress test (NST): Assessment of fetal well-being by evaluating the fetal heart’s ability to accelerate (speed up) in association with fetal movement by using an electronic fetal monitor; accelerations occur either spontaneously or in association with fetal movement. An external electronic monitor is applied while the woman is in a semi-Fowler’s or left-lateral position; conduction gel is put on the abdomen; two belts are applied on the woman’s abdomen; one belt and a device to detect fetal heart rate (FHR) and the other belt detects fetal movement; the woman is given a button to press, which records the time she feels movement on the strip on which the FHR is recorded. The test is continued for up to 40 minutes, or until the criteria for reactivity are met; because almost all accelerations are accompanied by fetal movement, the movement need not be recorded for the test to be reactive.	With adequate accelerations of the FHR, confirms that the placenta is functioning properly and that the fetus is well oxygenated with autonomic functions Blurred response indicative of hypoxia, acidosis, drugs, or fetal sleep Nonreactive NST indicates the fetal heartbeat does not accelerate adequately and further assessment may be required A reactive NST indicates the fetal heartbeat accelerated adequately with fetal movement
Contraction stress test (CST): Evaluation of the FHR response to mild uterine contractions by using an electronic fetal monitor. Contractions are induced by intravenous oxytocin (Pitocin) infusion or by self-stimulation of the nipples, which causes the woman’s pituitary gland to release oxytocin; the woman must have at least three contractions of at least 40-seconds duration in a 10-minute period for interpretation of the CST test.	Same purposes as for the NST Negative CST indicates there were no late decelerations of the FHR with three uterine contractions in a 10-minute period Variable accelerations that occur with CST may indicate cord compression
Nipple stimulation: Done if inadequate contractions occur. Woman brushes her palm across nipple for 2-3 minutes, stopping when contraction begins; after 5-minute rest period, same process is repeated. To avoid hyperstimulation (uterine contractions lasting 90 seconds or more often than every 2 minutes), bilateral stimulation should not be done unless unilateral stimulation fails.	Stimulate contractions to result in FHR accelerations Intermittent nipple stimulation preferred to prevent hyperstimulation of the uterus
Biophysical profile (BPP): Method to evaluate the condition of the fetus that uses five observations: fetal breathing movements, gross fetal movements (movements of body), FHR variability and reactivity (the NST), and the volume of amniotic fluid (amniotic fluid index [AFI]). Some facilities omit the NST, and others assess only the NST or ultrasound and AFI.	Used after 26 weeks’ gestation to assess fetal oxygenation; as fetal hypoxia increases, FHR changes occur first, then decreased breathing movement (<1 breath in 30 minutes), gross body movements (<3 in 20 minutes), and finally loss of muscle tone (failure to open and close the hand) Results immediately available and allow for delay of induction if fetal well-being is confirmed
Vibroacoustic stimulation test (vibration and sound): Stimulation of fetus by artificial larynx device; used as an adjunct to the NST. The artificial larynx is applied to the woman’s abdomen over the fetal head, then is activated with a 2- to 3-second stimulus.	Used to clarify whether fetus was sleeping (or inactive) during previous NST Has reduced number of nonreactive NSTs as well as time and cost Fetal accelerations in response to stimulus indicate fetal health
Maternal assessment of fetal movement (kick counts): Simple but valuable method for monitoring fetus. It should be encouraged after 28 weeks’ gestation, with women setting aside a consistent time to do the “kick counts.” Mother should count the number of fetal movements for 30-60 minutes 2-3 times a day; other protocols may be used.	Recognizes that the presence of fetal movements is a reassuring sign of fetal health. Decreased fetal movements possibly caused by sleep Cessation of movements correlated with hypoxia and fetal death In the third trimester, woman counts and documents fetal movement for 30-60 minutes twice a day; <4 movements in 30 minutes on 2 consecutive days or <10 movements in 12-hour period should be reported to the health care provider NOTE: Maternal use of drugs may affect fetal activity.
Amniotic fluid index (AFI): This ultrasound scan measures the amniotic fluid pockets in all 4 quadrants surrounding the mother’s umbilical area and produces an AFI. A reading of 15-19 cm is considered normal; <5 cm is known as oligohydramnios (decreased amniotic fluid); >30 cm is hydramnios (excess amniotic fluid).	Identifies oligohydramnios, which is associated with growth restriction and fetal distress during labor because of kinking of the umbilical cord Identifies hydramnios, which is associated with fetal anomalies such as gastrointestinal obstruction or fetal hydrops
Alpha-fetoprotein test (AFP): Determines the level of this protein in the pregnant woman’s blood serum (MSAFP) or in a sample of amniotic fluid (AFAFP). Correct interpretation requires accurate gestational age. The test is usually performed at 16-18 weeks’ gestation.	High levels associated with open defects such as spina bifida Low levels associated with chromosomal anomalies or hydatidiform mole
Triple marker screening: Detects levels of human chorionic gonadotropin (hCG) and unconjugated estriol. This is often done with AFP test.	May indicate trisomy 18 or 21 if estriol is low and hCG is high. May indicate trisomy 21 if Inhibin A is elevated

Nursing care during assessments of fetal health, especially with all of the new tests being performed, is important; the woman must understand the reason that specific tests are being performed. The nurse can provide an opportunity for the woman to ask questions regarding the procedure. Clarifying and interpreting test results should be carried out collaboratively by all health care providers involved in the procedures. However, the nurse is often the person who spends the most time with the woman (Nursing Care Plan 5-1 on p. 70).

Communication

Antepartum Fetal Test

Before any antepartum fetal test, parents should know the answer to each of these questions:

• What information will the test provide that is not already known?

• How will the information be used in the management of the mother and the baby?

• What is the risk for the mother and the baby?

• If an abnormal condition is detected, is treatment available?

Nursing Care Plan 5-1

Fetal Well-Being

Scenario

A multigravida (P2, G5) is 37 years old. The woman is approaching her twenty-fourth week of gestation. She has cut down on smoking. This pregnancy is unplanned, and financial status is unstable. She relates that her appetite has been poor when asked questions about her small amount of weight gain for the past 2 months. The certified nurse-midwife notes that fetal growth is delayed according to her estimated date of birth.

Selected Nursing Diagnosis

Deficient knowledge of conditions and equipment used

Expected Outcomes	Nursing Interventions	Rationales
Patient will verbalize understanding of procedure.	Explain nature of test being performed, whether invasive or noninvasive, and what she may experience.	Informing woman helps relieve anxiety and concern for fetal well-being.
Patient will be able to describe strengths and weaknesses of her understanding of potential outcomes of tests.	Review data to be obtained. This may be information about fetal growth, placental location, or number of fetuses.	Honest and open discussion promotes better understanding and trust. It satisfies need for recognition of value of data to be obtained.

Selected Nursing Diagnosis

Fear related to the unknown

Expected Outcomes	Nursing Interventions	Rationales
Patient will respond that all questions have been satisfactorily answered and will be able to discuss correctly.	Listen to woman’s concerns about the test(s) that have been scheduled.	Helps woman develop realistic view of situation.
Patient will state her understanding of what she is to do and will cooperate throughout the procedure.	Instruct the woman in specific terms regarding what she will be required to do if she must participate in obtaining any data.	Avoids fear of the unknown.
Patient will demonstrate bonding with nurse and confidence by responding positively to instructions.	Encourage verbalization; offer appropriate reassurance.	May reveal other concerns not yet addressed.

Selected Nursing Diagnosis

Pain related to invasive procedures

Expected Outcomes	Nursing Interventions	Rationales
Patient will maintain and verbalize comfort throughout the procedure(s).	Offer clear, simple, short explanations.	Provides opportunity for open communication at all times.
	Give her directions on slow, deep breathing in a calm, soothing manner.	Maintains a calm and confident, caring environment.
	Attempt to keep woman as comfortable and dry as possible.	Comfort increases compliance.

Selected Nursing Diagnosis

Anxiety related to external monitor used for nonstress test or contraction stress test of fetal heart rate

Expected Outcomes	Nursing Interventions	Rationales
Patient will state her understanding of what she is to do and will cooperate throughout the procedure.	Explain how and why electronic monitoring is used and what to expect.	Women and families sometimes express dissatisfaction with noise, beeps, and sounds of monitor and even concern that the monitor is a substitute for nursing care.
	Assure woman that someone will be with her or nearby continuously.	Reassures help is at hand.

Additional Nursing Diagnosis

Anxiety related to pregnancy and its outcome; ineffective health maintenance related to lack of material resources

Critical Thinking Questions

1. A woman in her twenty-fourth week of pregnancy states she is feeling fine and asks whether an ultrasound needs to be done. She states she does not want any invasive procedures done to her. How would you respond?

2. What are some nursing responsibilities in the care of a woman receiving an amnioinfusion after labor starts?

During the 9 months of pregnancy, women experience various types of discomforts, many of which are a result of normal physiologic changes that take place during pregnancy (discussed in Chapter 4). Nurses and other health care professionals often refer to these discomforts as minor, but the pregnant woman does not consider them minor. If discomforts are not anticipated or expected, they can make her feel anxious and worried. These discomforts can usually be relieved or prevented by simple measures (Table 5-3 on pp. 71–72). Teaching women about self-care is important (Figure 5-7 on p. 72).

Table 5-3

Self-Care for Common Discomforts of Pregnancy

Discomfort	Influencing Factors	Self-Care Measures
First Trimester
Nausea with or without vomiting	Elevation in hormones, decrease in gastric motility, fatigue, emotional factors; usually does not last beyond 16 weeks if vomiting persists, may lead to hyperemesis gravidarum	Avoid an empty stomach. Eat dry crackers or toast ½ to 1 hour before rising in the morning. Eat small, frequent meals. Drink fluids between meals. Avoid greasy, odorous, spicy, or gas-forming foods. Increase vitamin B6.
Breast tenderness	Increased vascular supply and hypertrophy of breast tissue caused by estrogen and progesterone Results in tingling, fullness, and tenderness	Wear a supportive bra (to alleviate tingling and tenderness). Avoid soap to the nipples (to prevent cracking).
Urinary frequency	Pressure of growing uterus on bladder in both first and third trimesters Progesterone relaxes smooth muscles of bladder	Void when urge is felt (to prevent urinary stasis); increase fluid intake during day. Decrease fluid in late evening to lessen nocturia; limit caffeine. Practice Kegel exercises.
Vaginal discharge (leukorrhea)	Increased production of mucus by endocervical glands in response to elevated estrogen levels and increased blood supply to the pelvic area, causing white, viscid vaginal discharge	Bathe or shower daily. Wear cotton underwear. Avoid tight undergarments and pantyhose. Keep the perineal area clean and dry. Avoid douching and using tampons. Wipe the perineal area from front to back after toileting. Contact health care provider if there is a change in color, odor, or character of discharge.
Second and Third Trimesters
Heartburn (pyrosis)	Increased production of progesterone causing relaxation of esophageal sphincter Regurgitation or backflow of gastric contents into the esophagus causing burning sensation behind the sternum, burping, and sour tastes in mouth	Sit up for 30 minutes after eating a meal. Avoid gas-forming and greasy foods. Avoid overeating. Use low-sodium liquid antacids such as Gelusil or Maalox (liquid will coat lining better than tablets); avoid sodium bicarbonate and Alka Seltzer.
Constipation and flatulence (gas)	Increased levels of progesterone causing bowel sluggishness, with increased water absorption (results in hardened stool) Pressure of enlarging uterus on intestine Diet, lack of exercise, and decreased fluids	Increase fluid intake (a minimum of 8 glasses per day, not including carbonated or caffeinated beverages because of their diuretic effect), roughage in diet, and exercise. Exercise to stimulate peristalsis.
	Iron supplements contributing to hardening of stools	Establish regular schedule for bowel movement. Do not take mineral oil or enemas. Consult health care provider about taking a stool softener (docusate).
Hemorrhoids	Varicosities (distended veins) of rectum caused by vascular enlargement of pelvis, straining from constipation, and descent of fetal head into pelvis May disappear after birth, when pressure is relieved	Use anesthetic ointment, cool witch hazel pads, or rectal suppositories. May disappear after birth, when pressure is relieved Take sitz baths, increase fiber in diet, and have regular bowel habits to avoid constipation.
Backaches	Result of the spine’s adaptation to posture changes as the uterus enlarges Enlarging uterus altering center of gravity, resulting in lordosis (exaggeration of lumbosacral curve) and muscle strain	Maintain correct posture with head up and shoulders back; use good body mechanics. Avoid exaggerating lumbar curve. Squat rather than bending over when picking up objects (bend at knees, not waist). Wear low-heeled shoes to help maintain better posture. Do exercises such as tailor sitting (cross-legged), shoulder circling, and pelvic rocking. Rest; applying localized heat may help.
Round ligament pain	Abdominal ligaments stretched by enlarging uterus, causing pain in lower abdomen after sudden movements	Avoid jerky or quick movements. Use pillow support for abdomen. Use good body mechanics.
Leg cramps	Pressure of uterus on blood vessels that impairs circulation to legs, causing muscle strain and fatigue Imbalance in the calcium/phosphorus ratio	Dorsiflex foot and straighten leg with downward pressure on knee or stand with feet flat on floor when cramps occur (see Figure 5-7). Evaluate diet and calcium intake.
Headache	Emotional tension and fatigue Increased circulatory blood volume and heart rate causing dilation and distention of cerebral vessels	Obtain emotional support. Practice relaxation exercises. Eat regular meals. If headaches continue, report to caregiver (potential gestational hypertension).
Varicose veins	Relaxation of smooth muscle in walls of veins caused by elevated progesterone Pressure of enlarging uterus causing pressure on veins, resulting in development of varicosities in vulva, rectum, and legs	Avoid lengthy standing or sitting, constrictive clothing, and bearing down during bowel movements. Walk frequently. Rest with legs elevated. Wear support stockings; avoid tight knee-highs. Exercise (to stimulate venous return). Relieve hemorrhoid swelling with warm sitz baths, local application of astringent compresses, or analgesic ointment.
Edema of feet and ankles	Circulatory congestion of lower extremities	Elevate legs when sitting. Increase rest periods. Avoid constrictive clothing and prolonged standing or sitting.
Faintness and dizziness	Vasomotor instability or postural hypotension Standing for long periods with venous stasis in lower extremities	Avoid sudden changes in position, prolonged standing, and warm crowded areas. Move slowly from rest position. Avoid hypoglycemia by eating 4-5 small meals daily. Lie on left side when resting to avoid supine hypotensive syndrome (pressure of uterus on vena cava). If symptoms do not lessen, report to caregiver.
Fatigue	Hormonal changes in early pregnancy and periodic hypoglycemia as glucose is used by embryo for rapid growth More prominent in early months of pregnancy	Try to get 8-10 hours of sleep. Take naps during the day if possible. Use relaxation techniques, meditation, or change of scenery.
Dyspnea	Later in pregnancy, caused by uterus rising into abdomen and pressing on diaphragm	Sleep with several pillows under head. Use deep chest breathing before going to sleep. Use proper posture while sitting or standing. Avoid exertion.

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