• Describe the process of confirming pregnancy and estimating the date of birth. • Summarize the physical, psychosocial, and behavioral changes that usually occur as the mother and other family members adapt to pregnancy. • Discuss the benefits of prenatal care and problems of accessibility for some women. • Outline the patterns of health care used to assess maternal and fetal health status at the initial and follow-up visits during pregnancy. • Identify the typical nursing assessments, diagnoses, interventions, and methods of evaluation in providing care for the pregnant woman. • Discuss education needed by pregnant women to understand physical discomforts related to pregnancy and to recognize signs and symptoms of potential complications. • Examine the impact of culture, age, parity, and number of fetuses on the response of the family to the pregnancy and on the prenatal care provided. Additional related content can be found on the companion website at evolve.elsevier.com/Lowdermilk/Maternity/ • Assessment Videos: Chest wall, breast, abdomen/fundal height, fetal heart rate • Case Study: Second Trimester • Critical Thinking Exercise: Discomforts of Pregnancy • Critical Thinking Exercise: Teenage Pregnancy • Nursing Care Plan: Adolescent Pregnancy • Nursing Care Plan: Discomforts of Pregnancy and Warning Signs • Spanish Guidelines: Assessment of Respiratory Symptoms • Spanish Guidelines: Prenatal Interview 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. 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. • 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. 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. 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). • Is this pregnancy planned or not, wanted or not? • Is the woman pleased, displeased, accepting, or nonaccepting? • What problems related to finances, career, or living accommodations will occur as a result of the pregnancy? Determine the family support system by asking: • What primary support is available to her? • Are changes needed to promote adequate support? • What are the existing relationships among the mother, father or partner, siblings, and in-laws? • What preparations is she making for her care and that of dependent family members during labor and for the care of the infant after birth? • Does she need financial, educational, or other support from the community? • What are the woman’s ideas about childbearing, her expectations of the infant’s behavior, and her outlook on life and the female role? Other such questions to ask include the following: • What does the woman think it will be like to have a baby in the home? • How is her life going to change by having a baby? 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). 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]).
Nursing Care of the Family during Pregnancy
Web Resources
Adaptation to Pregnancy
Maternal Adaptation
Accepting the Pregnancy
Preparing for childbirth
Paternal Adaptation
Accepting the pregnancy
Sibling Adaptation
Care Management
Initial Assessment
Social, experiential, and occupational history
History of physical abuse
Laboratory tests
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Nursing Care of the Family during Pregnancy
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