Nursing Care of the Family during Pregnancy



Nursing Care of the Family during Pregnancy


Deitra Leonard Lowdermilk





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The prenatal period is a time of physical and psychologic preparation for birth and parenthood. Becoming a parent is one of the milestones of adult life, and as such, it is a time of intense learning for both parents and those close to them. The prenatal period provides a unique opportunity for nurses and other members of the health care team to influence family health. During this period, essentially healthy women seek regular care and guidance. The nurse’s health-promotion interventions can affect the well-being of the woman, her unborn child, and the rest of her family for many years.


Regular prenatal visits, ideally beginning soon after the first missed menstrual period, offer opportunities to ensure the health of the expectant mother and her fetus. Prenatal health care permits diagnosis and treatment of preexisting maternal disorders and any disorder that may develop during the pregnancy. Prenatal care is designed to monitor the growth and development of the fetus and to identify any abnormalities that will interfere with the course of normal labor. Prenatal care also provides education and support for self-management and parenting.


Pregnancy spans 9 months, but health care providers do not use the familiar monthly calendar to determine fetal age or discuss the pregnancy. Instead, they use lunar months, which last 28 days, or 4 weeks. According to the lunar calendar, normal pregnancy lasts approximately 10 lunar months, which is the same as 40 weeks or 280 days. Health care providers also refer to early, middle, and late pregnancy as trimesters. The first trimester lasts from weeks 1 through 13; the second, from weeks 14 through 26; and the third, from weeks 27 through 40. A pregnancy is considered at term if it advances to the completion of 37 weeks.


The focus of this chapter is on meeting the health needs of the expectant family over the course of pregnancy, or the prenatal period.



Diagnosis of Pregnancy image


Women may suspect pregnancy when they miss a menstrual period. Many women come to the first prenatal visit after a positive home pregnancy test; however, the clinical diagnosis of pregnancy before the second missed period is difficult in some women. Physical variations, obesity, or tumors, for example, may confuse even the experienced examiner. Accuracy is important, however, because emotional, social, medical, or legal consequences of an inaccurate diagnosis, either positive or negative, can be extremely serious. A correct date for the last (normal) menstrual period (LMP or LNMP) and for the date of intercourse and a basal body temperature (BBT) record are of great value in the accurate diagnosis of pregnancy (see Chapter 4).




Estimating Date of Birth


After the diagnosis of pregnancy, the woman’s first question usually concerns when she will give birth. This date has traditionally been termed the estimated date of confinement (EDC), although estimated date of delivery (EDD) is also used. However, the term estimated date of birth (EDB) promotes a more positive perception of both pregnancy and birth. Because the precise date of conception is generally unknown, several formulas can be used for calculating the EDB. None of these guides is infallible, but Nägele’s rule is reasonably accurate and is usually used (Johnson, Gregory, & Niebyl, 2007).


Nägele’s rule is as follows: After determining the first day of the LMP, subtract 3 calendar months and add 7 days; or alternatively, add 7 days to the LMP and count forward 9 calendar months. Box 7-1 demonstrates use of Nägele’s rule. Nägele’s rule assumes that the woman has a 28-day menstrual cycle and that pregnancy occurred on the fourteenth day. Obtaining an accurate menstrual history is important as well in using this method of dating.




Adaptation to Pregnancy image


Pregnancy affects all family members, and each family member must adapt to the pregnancy and interpret its meaning in light of his or her own needs. This process of family adaptation to pregnancy takes place within a cultural environment influenced by societal trends. Dramatic changes have occurred in Western society in recent years, and the nurse needs to be prepared to support single-parent families, reconstituted families, dual-career families, and alternative families, as well as traditional families, in the childbirth experience.


Much of the research on family dynamics during pregnancy in the United States and Canada has focused on Caucasian, middle-class nuclear families. Hence the findings do not always apply to families that do not fit the traditional North American model. Adaptation of terms is appropriate to avoid embarrassment to the nurse and offense to the family. Additional research is needed on a variety of families to determine if study findings generated in traditional families are applicable to others.



Maternal Adaptation


Women of all ages use the months of pregnancy to adapt to the maternal role, a complex process of social and cognitive learning. Early in pregnancy, nothing seems to be happening, and a woman may spend much time sleeping. With the perception of fetal movement in the second trimester, the woman turns her attention inward to her pregnancy and to relationships with her mother and other women who have been or who are pregnant.


Pregnancy is a maturational milestone that is often stressful but also rewarding as the woman prepares for a new level of caring and responsibility. Her self-concept changes in readiness for parenthood as she prepares for her new role. She moves gradually from being self-contained and independent to being committed to a lifelong concern for another human being. This growth requires mastery of certain developmental tasks: accepting the pregnancy, identifying with the role of mother, reordering the relationships between herself and her mother and between herself and her partner, establishing a relationship with the unborn child, and preparing for the birth experience (Lederman, 1996). The partner’s emotional support is an important factor in the successful accomplishment of these developmental tasks. Single women with limited support may have difficulty making this adaptation.



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.



Paternal Adaptation


The father’s beliefs and feelings about the ideal mother and father and his cultural expectation of appropriate behavior during pregnancy affect his response to his partner’s need for him. One man may engage in nurturing behavior. Another may feel lonely and alienated as the woman focuses her physical and emotional attention on the unborn child. He may seek comfort and understanding outside the home or become interested in a new hobby or involved with his work. Some men view pregnancy as proof of their masculinity and their dominant role. To others, pregnancy has no meaning in terms of responsibility to either mother or child. However, for most men, pregnancy is a time of preparation for the parental role with intense learning.



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:



• The announcement phase may last from a few hours to a few weeks. The developmental task is to accept the biologic fact of pregnancy. Men react to the confirmation of pregnancy with joy or sadness, depending on whether the pregnancy is desired or unplanned or unwanted. Ambivalence in the early stages of pregnancy is common.


• If pregnancy is unplanned or unwanted, some men find the alterations in life plans and lifestyles difficult to accept. Some men engage in extramarital affairs for the first time during their partner’s pregnancy. Others batter their wives for the first time or escalate the frequency of battering episodes (Krieger, 2008). Chapter 2 provides information about violence against women and offers guidance on assessment and intervention.


• The second phase, the moratorium phase, is the period when he adjusts to the reality of pregnancy. The developmental task is to accept the pregnancy. Men appear to put conscious thought of the pregnancy aside for a time. They become more introspective and engage in many discussions about their philosophy of life, religion, childbearing, and childrearing practices and their relationships with family members, particularly with their father. Depending on the man’s readiness for the pregnancy, this phase may be relatively short or persist until the last trimester.


• The third phase, the focusing phase, begins in the last trimester and is characterized by the father’s active involvement in both the pregnancy and his relationship with his child. The developmental task is to negotiate with his partner the role he is to play in labor and to prepare for parenthood. In this phase the man concentrates on his experience of the pregnancy and begins to think of himself as a father.




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.



Sibling Adaptation


Sharing the spotlight with a new brother or sister may be the first major crisis for a child. The older child often experiences a sense of loss or feels jealous at being “replaced” by the new sibling. Some of the factors that influence the child’s response are age, the parents’ attitudes, the role of the father, the length of separation from the mother, the hospital’s visitation policy, and the way the child has been prepared for the change.


A mother with other children must devote time and effort to reorganizing her relationships with them. She needs to prepare siblings for the birth of the child (Fig. 7-4 and Box 7-2) and begin the process of role transition in the family by including the children in the pregnancy and being sympathetic to older children’s concerns about losing their places in the family hierarchy. No child willingly gives up a familiar position.



BOX 7-2   Tips for Sibling Preparation







Siblings’ responses to pregnancy vary with their age and dependency needs. The 1-year-old infant seems largely unaware of the process, but the 2-year-old child notices the change in his or her mother’s appearance and may comment that “Mommy’s fat.” The toddlers’ need for sameness in the environment makes the children aware of any change. They may exhibit more clinging behavior and sometime regress in toilet training or eating.


By age 3 or 4 years, children like to hear the story of their own beginning and to hear how their development compares with that of the present pregnancy. They like to listen to the fetal heartbeat and feel the baby moving in utero (see Fig. 7-2). Sometimes they worry about how the baby is being fed and what it wears.


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?” Children in this age group notice pregnant women in stores, churches, and schools and sometimes seem shy if they need to approach a pregnant woman directly. On the whole, they look forward to the new baby, see themselves as “mothers” or “fathers,” and enjoy buying baby supplies and preparing a place for the baby. Because they still think in concrete terms and base judgments on the here and now, they respond positively to their mother’s current good health.


Early and middle adolescents preoccupied with the establishment of their own sexual identity may have difficulty accepting the overwhelming evidence of the sexual activity of their parents. They reason that if they are too young for such activity, certainly their parents are too old. They seem to take on a critical parental role and may ask, “What will people think?” or “How can you let yourself get so fat?” or “How can you let yourself get pregnant?” Many pregnant women with teenage children will confess that the attitudes of their teenagers are the most difficult aspect of their current pregnancy.


Late adolescents do not appear to be unduly disturbed. They are busy making plans for their own lives and realize that they will soon be gone from home. Parents usually report they are comforting and act more as other adults than as children.



Grandparent Adaptation


Every pregnancy affects all family relationships. For expectant grandparents, a first pregnancy in a child is undeniable evidence that they are growing older. Many think of a grandparent as old, white-haired, and becoming feeble of mind and body; however, some people face grandparenthood while still in their thirties or forties. Some individuals react negatively to the news that they will be grandparents, indicating that they are not ready for the new role.


In some family units, expectant grandparents are nonsupportive and inadvertently decrease the self-esteem of the parents-to-be. Mothers may talk about their terrible pregnancies, fathers may discuss the endless cost of rearing children, and mothers-in-law may complain that their sons are neglecting them because their concern is now directed toward the pregnant daughters-in-law.


However, most grandparents are delighted at the prospect of a new baby in the family. It reawakens the feelings of their own youth, the excitement of giving birth, and their delight in the behavior of the parents-to-be when they were infants. They set up a memory store of the child’s first smiles, first words, and first steps, which they can use later for “claiming” the newborn as a member of the family. These behaviors provide a link between the past and present for the parents- and grandparents-to-be.


In addition, the grandparent is the historian who transmits the family history, a resource who shares knowledge based on experience, a role model, and a support person. The grandparent’s presence and support can strengthen family systems by widening the circle of support and nurturance (Fig. 7-5).




Care Management image


The purpose of prenatal care is to identify existing risk factors and other deviations from normal in order to enhance pregnancy outcomes (Johnson, Gregory, & Niebyl, 2007). Major emphasis is placed on preventive aspects of care, primarily to motivate the pregnant woman to practice optimal self-management and to report unusual changes early so as to minimize or prevent problems. In holistic care, nurses provide information and guidance about not only the physical changes, but also the psychosocial impact of pregnancy on the woman and members of her family. The goals of prenatal nursing care, therefore, are to foster a safe birth for the infant and to promote satisfaction of the mother and family with pregnancy and the birth experience.


Advances have occurred in the number of women in the United States who receive adequate prenatal care. In 2005, almost 84% of all women received care in the first trimester. African-American, Hispanic, and Native-American women were two times as likely to get late prenatal care or no care at all than Caucasian women (Martin et al., 2008). Although women of middle or high socioeconomic status routinely seek prenatal care, women living in poverty or who lack health insurance are not always able to use public medical services or gain access to private care. Lack of culturally sensitive care providers and barriers in communication resulting from differences in language also interfere with access to care (Darby, 2007). Similarly, immigrant women who come from cultures in which prenatal care is not emphasized may not know to seek routine prenatal care. Birth outcomes in these populations are less positive, with higher rates of maternal and fetal or newborn complications. Problems with low birth weight (LBW; less than 2500 g) and infant mortality have in particular been associated with lack of adequate prenatal care.


Barriers to obtaining health care during pregnancy include lack of transportation, unpleasant clinic facilities or procedures, inconvenient clinic hours, child care problems and personal attitudes (American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, 2006; Daniels, Noe, & Mayberry, 2006; Johnson, Hatcher, et al., 2007). The increasing use of advanced practice nurses in collaborative practice with physicians can help improve the availability and accessibility of prenatal care. A regular schedule of home visiting by nurses during pregnancy has also proven effective (Dawley & Beam, 2005).


The current model for provision of prenatal care has been used for more than a century. The initial visit usually occurs in the first trimester, with visits every four weeks through week 28 of pregnancy. Thereafter, visits are scheduled every 2 weeks until week 36 and then every week until birth (American Academy of Pediatrics and American College of Obstetricians and Gynecologists [2007]) (Box 7-3). 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 (Villar, Carroli, Khan-Neelofur, Piaggio, & Gulmezoglu, 2001; Walker, McCully, & Vest, 2001).



CenteringPregnancy® is a care model that is gaining in popularity. This model is one of group prenatal care in which authority is shifted from the provider to the woman and other women who have similar due dates. The model creates an atmosphere that facilitates learning, encourages discussion, and develops mutual support. Most care takes place in the group setting after the first visit and continues for 10 2-hour sessions scheduled throughout the pregnancy (Moos, 2006) (see Box 7-3). At each meeting the first 30 minutes is spent in completing assessments (by self and by 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 encourage to participate (Massey, Rising, & Ickovics, 2006; Reid, 2007).


Prenatal care is ideally a multidisciplinary activity in which nurses work with physicians or midwives, nutritionists, social workers, and others. Collaboration among these individuals is necessary to provide holistic care. The case management model, which makes use of care maps and critical pathways, is one system that promotes comprehensive care with limited overlap in services. To emphasize the nursing role, care management for the initial visit and follow-up visits is organized around the central elements of the nursing process: assessment, nursing diagnoses, expected outcomes, plan of care and interventions, and evaluation (see Nursing Process box).



Nursing Process


Prenatal Care




Nursing Diagnoses


The following are examples of the nursing diagnoses that may be appropriate in the prenatal period:







Initial Assessment


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. A prenatal history form (paper or electronic) is often used to document information obtained. The pregnant woman and family members who may accompany the woman for her care need to know that the first prenatal visit is more lengthy and detailed than future visits. In some clinics and offices, women may have the diagnostic tests done first and have the prenatal history and physical examination at the next visit.







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).




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.





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.




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]).



BOX 7-4


HIV Screening




• Pregnant women are ethically obligated to seek reasonable care during pregnancy and to avoid causing harm to the fetus. Women’s health nurses should be advocates for the fetus while accepting of the pregnant woman’s decision regarding testing and/or treatment for HIV.


• The incidence of perinatal transmission from an HIV-positive mother to her fetus ranges from 16% to 25%. Triple drug antiviral or highly active antiretroviral therapy (HAART) during pregnancy decreases perinatal transmission to as low as 1% to 2% (Burr, 2011).


• The CDC (2010) recommends testing for HIV infections for all pregnant women as early as possible in pregnancy and a second test in the third trimester, ideally before 36 weeks. This is especially important for women known to be at high risk for HIV infection.


• Testing has the potential to identify HIV-positive women who can then be treated. Health care providers have an obligation to ensure that pregnant women are well informed about HIV symptoms, testing, and methods of decreasing maternal-fetal transmission. The Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) recommend universal opt-out screening, which means that all pregnant women are offered HIV screening but have the opportunity to opt out if desired (ACOG Committee on Obstetric Practice, 2011; CDC, 2010). The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN, 2008) supports this system of HIV screening that allows all pregnant women to be offered screening.


Data from American College of Obstetricians and Gynecologists Committee on Obstetric Practice: Committee Opinion No. 418. (2011). Prenatal and perinatal human immunodeficiency virus testing expanded recommendations. Obstetrics and Gynecology, 104(5 Part 1),1119-1124; AWHONN. (2008). HIV screening procedures for pregnant women and newborns policy position statement, Washington: DC; Burr, C. (2011). Reducing maternal-infant HIV transmission. In S. Coffey (Ed.). Guide for HIV/AIDS clinical care. Rockville: MD; U.S. Department of Health and Human Services, Health Resources and Services Administration, hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-402_pmtct.html; Centers for Disease Control and Prevention. (2010). Sexually transmitted diseases treatment guidelines. MMWR Morbidity and Mortality Weekly Report 59(RR12), 1-110.

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Oct 8, 2016 | Posted by in NURSING | Comments Off on Nursing Care of the Family during Pregnancy
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