Accepting the Pregnancy

The first step in adapting to the maternal role is accepting the idea of pregnancy and assimilating the pregnant state into the woman’s way of life. Mercer (1995) described this process as cognitive restructuring and credited Reva Rubin (1984) as the nurse theorist who pioneered our understanding of maternal role attainment. The degree of acceptance is reflected in the woman’s emotional responses. Many women are upset initially at finding themselves pregnant, especially if the pregnancy is unintended. Eventual acceptance of pregnancy parallels the growing acceptance of the reality of a child. However, do not equate nonacceptance of the pregnancy with rejection of the child; a woman may dislike being pregnant but feel love for the unborn child.

Women who are happy and pleased about their pregnancy often view it as biologic fulfillment and part of their life plan. They have high self-esteem and tend to be confident about outcomes for themselves, their babies, and other family members. Despite a general feeling of well-being, many women are surprised to experience emotional lability, or rapid and unpredictable changes in mood. These swings in emotions and increased sensitivity to others are disconcerting to the expectant mother and those around her. Increased irritability, explosions of tears and anger, and feelings of great joy and cheerfulness alternate, apparently with little or no provocation.

Profound hormonal changes that are part of the maternal response to pregnancy are responsible for mood changes. Other reasons such as concerns about finances and changed lifestyle contribute to this seemingly erratic behavior.

Most women have ambivalent feelings during pregnancy whether the pregnancy was intended or not. Ambivalence—having conflicting feelings simultaneously—is a normal response for people preparing for a new role. For example, during pregnancy, some women feel great pleasure that they are fulfilling a lifelong dream, but they also feel great regret that life as they now know it is ending.

Even women who are pleased to be pregnant may experience feelings of hostility toward the pregnancy or unborn child from time to time. Such incidents as a partner’s chance remark about the attractiveness of a slim, nonpregnant woman or news of a colleague’s promotion can give rise to ambivalent feelings. Body sensations, feelings of dependence, or the realization of the responsibilities of child care also can generate such feelings.

Intense feelings of ambivalence that persist through the third trimester may indicate an unresolved conflict with the motherhood role (Mercer, 1995). After the birth of a healthy child, memories of these ambivalent feelings are usually dismissed. If the child is born with a defect, however, a woman may look back at the times when she did not want the pregnancy and feel intensely guilty. She may believe that her ambivalence caused the birth defect. She will then need assurance that her feelings were not responsible for the problem.

Identifying with the mother role

The process of identifying with the mother role begins early in each woman’s life when she is being mothered as a child. Her social group’s perception of the feminine role can subsequently influence her toward choosing between motherhood or a career, being married or single, being independent rather than interdependent, or being able to manage multiple roles. Practice roles, such as playing with dolls, baby-sitting, and taking care of siblings, increase her understanding of what being a mother involves.

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

Reordering personal relationships

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

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

The mother’s reaction to the daughter’s pregnancy signifies her acceptance of the grandchild and of her daughter. If the mother is supportive, the daughter has an opportunity to discuss pregnancy, labor, and her feelings with a knowledgeable and accepting woman (Fig. 7-1). Reminiscing about the pregnant woman’s early childhood and sharing the prospective grandmother’s account of her childbirth experience help the daughter to anticipate and prepare for labor and birth.

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. Women express two major needs within this relationship during pregnancy: feeling loved and valued and having the child accepted by the partner.

The marital or committed relationship is not static but evolves over time. The addition of a child changes forever the nature of the bond between partners. This is often a time when couples grow closer, and the pregnancy has a maturing effect on the partners’ relationship as they assume new roles and discover new aspects of one another. Partners who trust and support each other are able to share mutual-dependency needs (Mercer, 1995).

Sexual expression during pregnancy is highly individualized. Physical, emotional, and interactional factors, including misinformation about sex during pregnancy, sexual dysfunction, and physical changes in the woman, affect the sexual relationship. Many women and their partners express anxiety about the presence of the fetus as a third party in lovemaking. An individual may also believe that anomalies, mental retardation, and other injuries to the fetus and mother occur during sexual relations in pregnancy. Some couples fear that the birth process will drastically change the woman’s genitals. Some couples do not express their concerns to the health care provider because of embarrassment or because they do not want to appear foolish.

As pregnancy progresses, changes in body shape, body image, and levels of discomfort influence both partners’ desire for sexual expression. During the first trimester, the woman’s sexual desire often decreases, especially if she has breast tenderness, nausea, fatigue, or sleepiness. As she progresses into the second trimester, however, her sense of well-being combined with the increased pelvic congestion that occurs at this time may increase her desire for sexual release. In the third trimester, somatic complaints and physical bulkiness increase physical discomfort and again diminish interest in sex. As a woman’s pregnancy progresses, her enlarging gravid abdomen may limit the use of the man-on-top position for intercourse. Therefore other positions (e.g., side to side or the woman on top) may allow intercourse and minimize pressure on the woman’s abdomen (Westheimer & Lopater, 2005).

Partners need to feel free to discuss their sexual responses during pregnancy with each other and with their health care provider. Their sensitivity to each other and willingness to share concerns can strengthen their sexual relationship. Partners who do not understand the rapid physiologic and emotional changes of pregnancy can become confused by the other’s behavior. By talking to each other about the changes they are experiencing, couples can define problems and then offer the needed support. Nurses can facilitate communication between partners by talking to expectant couples about possible changes in feelings and behaviors they will experience as pregnancy progresses (see later discussion).

Establishing a relationship with the fetus

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

In phase 1 the woman accepts the biologic fact of pregnancy. She needs to be able to state, “I am pregnant” and incorporate the idea of a child into her body and self-image. The woman’s thoughts center on herself and the reality of her pregnancy. The child is viewed as part of herself, not a separate and unique person.

In phase 2 the woman accepts the growing fetus as distinct from herself, usually accomplished by the fifth month. She can now say, “I am going to have a baby.” This differentiation of the child from the woman’s self permits the beginning of the mother-child relationship that involves not only caring, but also responsibility. Planned pregnancies usually enhance attachment of a mother to her child, and the attachment increases when ultrasound examination and quickening confirm the reality of the fetus.

With acceptance of the reality of the child (hearing the heartbeat and feeling the child move) and an overall feeling of well-being the woman enters a quiet period and becomes more introspective. Fantasies about the child become precious to the woman. As the woman seems to withdraw and to concentrate her interest on the unborn child, her partner sometimes feels left out. If other children are in the family, they may become more demanding in their efforts to redirect the mother’s attention to themselves.

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

Although the mother alone experiences the child within, both parents and siblings believe the unborn child responds in a very individualized, personal manner. Family members may interact a great deal with the unborn child by talking to the fetus and stroking the mother’s abdomen, especially when the fetus shifts position (Fig. 7-2). The fetus may even have a nickname used by family members.

Preparing for childbirth

Many women actively prepare for birth by reading books, viewing films, attending parenting classes, and talking to other women. They seek the best caregiver possible for advice, monitoring, and caring. The multiparous woman has her own history of labor and birth, which influences her approach to preparation for this childbirth experience.

Anxiety can arise from concern about a safe passage for herself and her child during the birth process (Mercer, 1995; Rubin, 1975). Some women do not express this concern overtly, but they give cues to the nurse by making plans for care of the new baby and other children in case “anything should happen.” These feelings persist despite statistical evidence about the safe outcome of pregnancy for mothers and their infants. Many women fear the pain of childbirth or mutilation because they do not understand anatomy and the birth process. Education can alleviate many of these fears. Women also express concern over what behaviors are appropriate during the birth process and whether caregivers will accept them and their actions.

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

Accepting the pregnancy

The ways fathers adjust to the parental role has been the subject of considerable research. In older societies the man enacted the ritual couvade; that is, he behaved in specific ways and respected taboos associated with pregnancy and giving birth so the man’s new status was recognized and endorsed. Now, some men experience pregnancy-like symptoms, such as nausea, weight gain, and other physical symptoms. This phenomenon is known as the couvade syndrome. Changing cultural and professional attitudes have encouraged fathers’ participation in the birth experience in the last 30 years (Fig. 7-3).

The man’s emotional responses to becoming a father, his concerns, and his informational needs change during the course of pregnancy. Phases of the developmental pattern become apparent. May (1982) described three phases characterizing the developmental tasks experienced by the expectant father:

Identifying with the father role

Each man brings to pregnancy attitudes that affect the way in which he adjusts to the pregnancy and parental role. His memories of the fathering he received from his own father, the experiences he has had with child care, and the perceptions of the male and father roles within his social group will guide his selection of the tasks and responsibilities he will assume. Some men are highly motivated to nurture and love a child. Some are excited and pleased about the anticipated role of father. Others are more detached or even hostile to the idea of fatherhood.

Reordering personal relationships

The partner’s main role in pregnancy is to nurture and respond to the pregnant woman’s feelings of vulnerability. The partner must also deal with the reality of the pregnancy. The partner’s support indicates involvement in the pregnancy and preparation for attachment to the child.

Some aspects of a partner’s behavior indicate rivalry, and it is especially evident during sexual activity. For example, men may protest that fetal movements prevent sexual gratification or that they are being watched by the fetus during sexual activity. However, feelings of rivalry are often unconscious and not verbalized, but they are expressed in subtle behaviors.

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

Establishing a relationship with the fetus

The father-child attachment can be as strong as the mother-child relationship, and fathers can be as competent as mothers in nurturing their infants. The father-child attachment also begins during pregnancy. A father may rub or kiss the maternal abdomen, try to listen, talk, or sing to the fetus, or play with the fetus as he notes movement. Calling the unborn child by name or nickname helps to confirm the reality of pregnancy and promote attachment.

Men prepare for fatherhood in many of the same ways as women do for motherhood—by reading and by fantasizing about the baby. Daydreaming about their role as father is common in the last weeks before the birth; men rarely describe their thoughts unless they are reassured that such daydreams are normal.

Preparing for childbirth

The days and weeks immediately before the expected day of birth are full of anticipation and anxiety. Boredom and restlessness are common as the couple focuses on the birth process. However, during the last 2 months of pregnancy, many expectant fathers experience a surge of creative energy at home and on the job. They may become dissatisfied with their present living space. If possible, they tend to act on the need to alter the environment (remodeling, painting, etc.). This activity is their way of sharing in the childbearing experience. They are able to channel the anxiety and other feelings experienced during the final weeks before birth into productive activities. This behavior earns recognition and compliments from friends, relatives, and their partners.

Major concerns for the man are getting the woman to a medical facility in time for the birth and not appearing ignorant. Many men want to be able to recognize labor and determine when it is appropriate to leave for the hospital or call the physician or nurse-midwife. They may fantasize different situations and plan what they will do in response to them, or they may rehearse taking various routes to the hospital, timing each route at different times of the day.

Some prospective fathers have questions about the labor suite’s furniture, nursing staff, and location, as well as the availability of the physician and anesthesiologist. Others want to know what is expected of them when their partners are in labor. The man may also have fears concerning safe passage of his child and partner and the possible death or complications of his partner and child. He should verbalize these fears, otherwise he cannot help his mate deal with her own unspoken or spoken apprehension.

With the exception of childbirth preparation classes, a man has few opportunities to learn ways to be an involved and active partner in this rite of passage into parenthood. Mothers often sense the tensions and apprehensions of the unprepared, unsupportive father, and it often increases their fears.

The same fears, questions, and concerns may affect birth partners who are not the biologic fathers. Nurses need to keep birth partners informed, supported, and included in all activities in which the mother desires their participation. The nurse can do much to promote pregnancy and birth as a family experience.

Interview

The therapeutic relationship between the nurse and the woman is established during the initial assessment interview. Two types of data are collected: the woman’s subjective appraisal of her health status and the nurse’s objective observations.

One or more family members will often accompany the pregnant woman. With her permission, include those accompanying the woman in the initial prenatal interview. The observations and information about the woman’s family are then included in the database. For example, if the woman has small children with her the nurse can ask about her plans for child care during the time of labor and birth. Note any special needs at this time (e.g., wheelchair access, assistance in getting on and off the examining table, and cognitive deficits).

Reason for seeking care

Although pregnant women are scheduled for “routine” prenatal visits, they often come to the health care provider seeking information or reassurance about a particular concern. The woman’s chief concerns are recorded in her own words; this helps other personnel identify the priority of needs as identified by the woman. At the initial visit the desire for information about what is normal in the course of pregnancy is typical.

Current pregnancy

The presumptive signs of pregnancy may be of great concern to the woman. A review of symptoms she is experiencing and how she is coping with them helps to establish a database to develop a plan of care. The nurse can provide some early teaching at this time.

Obstetric and gynecologic history

Data are gathered on the woman’s age at menarche, menstrual history, and contraceptive history; the nature of any infertility or gynecologic conditions; her history of any sexually transmitted infections (STIs); her sexual history; and a detailed history of all her pregnancies, including the present pregnancy, and their outcomes. Note the date of the last Papanicolaou (Pap) test and the result. Obtain the date of her LMP to establish the EDB.

Medical history

The medical history includes specific medical or surgical conditions that may affect the pregnancy or that may be affected by the pregnancy. For example, a pregnant woman who has diabetes, hypertension, or epilepsy requires special care. Because most women are anxious during the initial interview, pay attention to cues, such as a MedicAlert bracelet, and prompt the woman to explain allergies, chronic diseases, or medications being taken (e.g., cortisone, insulin, anticonvulsants).

The woman should also describe the nature of previous surgical procedures. If a woman has undergone uterine surgery or extensive repair of the pelvic floor, then a cesarean birth may be necessary; appendectomy rules out appendicitis as a cause of right lower quadrant pain in pregnancy; and spinal surgery may contraindicate the use of spinal or epidural anesthesia. Note any injury involving the pelvis.

Women who have chronic or handicapping conditions often forget to mention them during the initial assessment because they have become so adapted to them. Special shoes or a limp may indicate the existence of a pelvic structural defect, which is an important consideration in pregnant women. The nurse who observes these special characteristics and inquires about them sensitively can obtain individualized data that will provide the basis for a comprehensive nursing care plan (Smeltzer, 2007).

Nutritional history

The woman’s nutritional history is an important component of the prenatal history because her nutritional status has a direct effect on the growth and development of the fetus. A dietary assessment will reveal special diet practices, food allergies, eating behaviors, the practice of pica, and other factors related to her nutritional status. Pregnant women are usually motivated to learn about good nutrition and respond well to nutritional advice generated by this assessment. (See Chapter 8 for further discussion.)

History of drug and herbal preparations use

A woman’s past and present use of legal (over-the-counter [OTC] and prescription medications, herbal preparations, caffeine, alcohol, nicotine) and illegal (marijuana, cocaine, heroin) drugs is assessed. This assessment is needed because many substances cross the placenta and may harm the developing fetus. Periodic urine toxicologic screening tests are often recommended during the pregnancies of women who have a history of illegal drug use. In some states of the United States, these test results have been used for criminal prosecution, which violates the patient-provider relationship and ethical responsibilities to the patient (Harris & Paltrow, 2003). To preserve constitutional rights and the ethical patient-provider relationship, drug-testing policies should encourage open communication between patient and physician, emphasize the availability of treatment options, and advocate for the health of woman and child.

Family history

The family history provides information about the woman’s immediate family, including her parents, siblings, and children. Information about the immediate family of the father of the baby is also important. These data help identify familial or genetic disorders or conditions that could affect the present health status of the woman or her fetus.

Social, experiential, and occupational history

Situational factors such as the family’s ethnic and cultural background and socioeconomic status can be assessed over several encounters. Explore the woman’s perception of this pregnancy by asking her questions such as the following:

Determine the family support system by asking:

Other such questions to ask include the following:

During interviews throughout the pregnancy the nurse should remain alert to the appearance of potential parenting problems, such as depression, lack of family support, and inadequate living conditions. The nurse needs to assess the woman’s attitude toward health care, particularly during childbearing, her expectations of health care providers, and her view of the relationship between herself and the nurse.

Coping mechanisms and patterns of interacting are identified. Early in the pregnancy the nurse should determine the woman’s knowledge of pregnancy, maternal changes, fetal growth, self-management, and care of the newborn, including feeding. Asking about attitudes toward unmedicated or medicated childbirth and about her knowledge of the availability of parenting skills classes is important. Before planning for nursing care the nurse needs information about the woman’s decision-making abilities and living habits (e.g., exercise, sleep, diet, diversional interests, personal hygiene, clothing). Common stressors during childbearing include the baby’s welfare, labor and birth process, behaviors of the newborn, the woman’s relationship with the baby’s father and her family, changes in body image, and physical symptoms.

Explore attitudes concerning the range of acceptable sexual behavior during pregnancy by asking questions such as the following: What has your family (partner, friends) told you about sex during pregnancy? Give more emphasis to the woman’s sexual self-concept by asking questions such as the following: How do you feel about the changes in your appearance? How does your partner feel about your body now? How do you feel about wearing maternity clothes?

History of physical abuse

All women should be assessed for a history or risk of physical abuse, particularly because the likelihood of abuse increases during pregnancy. Although a woman’s appearance or behavior may suggest the possibility of abuse, do not limit questioning to only those women who fit the supposed profile of the battered woman. Identification of abuse and immediate clinical intervention that includes information about safety will help prevent future abuse and increase the safety and well-being of the woman and her infant (Krieger, 2008) (see Fig. 2-11).

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

Battering and pregnancy in teenagers constitute a particularly difficult situation. Some adolescents are trapped in the abusive relationship because of their inexperience. Many professionals and the adolescents themselves ignore the violence because it may not be believable, because relationships are transient, and because the jealous and controlling behavior is interpreted as love and devotion. Routine screening for abuse and sexual assault is recommended for pregnant adolescents. (Family Violence Prevention Fund, 2009). Because pregnancy in young adolescent girls is commonly the result of sexual abuse, assess the desire to maintain the pregnancy.

Review of systems

During this portion of the interview, ask the woman to identify and describe preexisting or concurrent problems in any of the body systems. Assess her mental status as well. Question the woman about physical symptoms she has experienced, such as shortness of breath or pain. Pregnancy affects and is affected by all body systems; therefore information on the present status of the body systems is important in planning care. For each sign or symptom described, obtain the following additional data: body location, quality, quantity, chronology, aggravating or alleviating factors, and associated manifestations (onset, character, course) (Seidel, Ball, Dains, & Benedict, 2006).

Physical examination

The initial physical examination provides the baseline for assessing subsequent changes. The examiner should determine the woman’s needs for basic information regarding reproductive anatomy and provide this information, along with a demonstration of the equipment that may be used and an explanation of the procedure itself. The interaction requires an unhurried, sensitive, and gentle approach with a straightforward attitude.

The physical examination begins with assessment of vital signs, including height and weight (for calculation of body mass index [BMI]) and blood pressure (BP). The bladder should be empty before pelvic examination. A urine specimen may be obtained to test for protein, glucose, or leukocytes or for other urine tests.

Each examiner develops a routine for proceeding with the physical examination; most choose the head-to-toe progression. The examiner evaluates heart and lung sounds, and examines extremities. Distribution, amount, and quality of body hair are of particular importance because the findings reflect nutritional status, endocrine function, and attention to hygiene. The examiner assesses the thyroid gland thoroughly. The height of the fundus is noted if the first examination is performed after the first trimester of pregnancy. During the examination the examiner needs to remain alert to cues that indicate a potential threatening condition, such as supine hypotension—low BP that occurs while the woman is lying on her back, causing feelings of faintness. See Chapter 2 for a detailed description of the physical examination.

Whenever a pelvic examination is performed, the examiner assesses the tone of the pelvic musculature and the woman’s knowledge of Kegel exercises. Particular attention is paid to the size of the uterus because this assessment provides useful information on gestational age. One vaginal examination during early pregnancy is recommended, but another is usually not performed unless medically indicated.

Laboratory tests

The laboratory data yielded by the analysis of the specimens obtained during the examination provide important information concerning the symptoms of pregnancy and the woman’s health status.

Specimens are collected at the initial visit so that the cause of any abnormal findings can be treated. Blood is drawn for a variety of tests (Table 7-1). A sickle cell screen is recommended for women of African, Asian, or Middle Eastern descent, and testing for antibody to the human immunodeficiency virus (HIV) is strongly recommended for all pregnant women (Box 7-4). In addition, pregnant women and fathers with a family history of cystic fibrosis and of Caucasian ethnicity may want to have blood drawn for testing to determine if they are a cystic fibrosis carrier (Fries, Bashford, & Nunes (2005). Urine specimens are usually tested by dipstick; culture and sensitivity tests are ordered as necessary. During the pelvic examination, cervical and vaginal smears may be obtained for cytologic studies and for diagnosis of infection (e.g., Chlamydia, gonorrhea, group B Streptococcus [GBS]).

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