Nursing Care of the Family During Pregnancy

Chapter 8


Nursing Care of the Family During Pregnancy


Kathryn R. Alden



The prenatal period is a time of physical and psychologic preparation for birth and parenthood. Becoming a parent is one of the maturational milestones of adult life. It is a time of intense learning for 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 optimize the health of the expectant mother and her fetus. Prenatal health care permits diagnosis and treatment of preexisting maternal disorders and those that may develop during the pregnancy. Care is designed to monitor the growth and development of the fetus and identify abnormalities that can interfere with the course of normal labor and birth. The woman and her family can seek support to reduce stress and learn parenting skills.


In recent years, the concept of preconception care has been recognized as an important contributor to good pregnancy outcomes (see Chapter 3). If women can be taught healthy lifestyle behaviors and then practice them before conception—specifically, good nutrition, entering pregnancy with as healthy a weight as possible, adequate intake of folic acid, avoidance of alcohol and tobacco use, prevention of sexually transmitted infections (STIs) and other health hazards—a healthier pregnancy may result. Likewise, women who have health problems related to chronic diseases such as diabetes mellitus can be counseled regarding their special needs with the intent to minimize maternal and fetal complications.


Pregnancy spans 9 calendar months. However, health care providers use the concept of lunar months, which last 28 days (or 4 weeks), to describe the duration of pregnancy or gestational age. Thus normal pregnancy lasts about 10 lunar months, that is, 40 weeks, or 280 days. Pregnancy is divided into three 3-month periods, or trimesters. The first trimester covers weeks 1 through 13; the second, weeks 14 through 26; and the third, weeks 27 through term gestation (38 to 40 weeks). The focus of this chapter is on working with the expectant family to promote a healthy pregnancy that culminates in the birth of a healthy baby.



Diagnosis of Pregnancy


Women often suspect pregnancy when they miss a menstrual period. Many women come to the first visit after a positive home pregnancy test; however, the clinical diagnosis of pregnancy before the second missed period can be difficult in some women. Physical variations, obesity, or tumors, for example, can confound even the experienced examiner. Accuracy is important because emotional, social, medical, or legal consequences related to an inaccurate diagnosis, either positive or negative, can be extremely serious. A correct date for the first day of the last (normal) menstrual period (LMP), the date of intercourse, and a basal body temperature record can be of great value in the accurate diagnosis of pregnancy (see Chapter 5).




Estimating Date of Birth


When pregnancy is confirmed, the woman’s first question usually concerns when she will give birth. This date has traditionally been called the estimated date of confinement or estimated date of delivery. However, to promote a more positive perception of both pregnancy and birth, the term estimated date of birth (EDB) is now used. Accurate dating of pregnancy and calculation of the EDB have implications for timing of specific prenatal screening tests, assessing fetal growth, and making critical decisions for managing pregnancy complications. Ultrasound dating of gestational age is accurate, especially during the first half of pregnancy (ACOG, 2009).


Because the exact date of conception is usually unknown, several formulas have been suggested for calculating the EDB. None of these guides are infallible, but Nägele’s rule is reasonably accurate and a commonly used method.


Nägele’s rule is as follows: after determining the first day of the LMP, subtract 3 months, add 7 days and 1 year; or add 7 days to the LMP and count forward 9 months. For example, if the first day of the LMP was September 10, 2014, the EDB is June 17, 2015.


Nägele’s rule assumes that the woman has a 28-day menstrual cycle and that the pregnancy occurred on the fourteenth day of the cycle. An adjustment is in order if the cycle is longer or shorter than 28 days. Only about 5% of pregnant women give birth spontaneously on the EDB as determined by Nägele’s rule. Most women give birth during the period extending from 7 days before to 7 days after the EDB.



Adaptation to Pregnancy


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 must be prepared to support not only traditional families but also single-parent families, reconstituted families, dual-career families, and alternative families.


Much of the research on family dynamics in pregnancy in the United States and Canada has been done with Caucasian, middle-class nuclear families. Therefore findings may not apply to families who do not fit the traditional North American model. Adaptation of terms is appropriate to avoid offense to the family and embarrassment to the nurse. 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.


Pregnancy is a maturational milestone that can be 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. The partner’s presence and emotional support are important factors 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 Rubin (1975, 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. Initially, many women are dismayed at finding themselves pregnant, especially if the pregnancy is unplanned or unintended. Eventual acceptance of pregnancy parallels the growing acceptance of the reality of a child. Nonacceptance of the pregnancy should not be equated with rejection of the child. A woman may dislike being pregnant but feel love for the child to be born.


Women who are happy and pleased about their pregnancy 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 pregnant women are surprised to experience emotional lability, that is, 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 may be responsible for mood changes.


Most women have ambivalent feelings during pregnancy, whether or not the pregnancy was intended. Ambivalence—having conflicting feelings at the same time—is considered a normal response for people preparing for a new role. For example, during pregnancy, women may feel great pleasure that they are fulfilling a lifelong dream but they also may 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 the 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 can indicate an unresolved conflict with the motherhood role (Mercer, 1995). After the birth of a healthy child, memories of these ambivalent feelings usually are dismissed. If the child is born with a defect, a woman may look back at the times when she did not want the pregnancy and feel intense guilt. She may believe that her ambivalence caused the birth defect. She will then need reassurance 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 cultural and social group’s perception of what constitutes 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 may increase her understanding of what being a mother entails.


Many women have always wanted a baby; they enjoy children and look 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 as she prepares emotionally for the new role of mother. As family members learn their new roles, periods of tension and conflict can occur. 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 relationship with her mother is significant in adapting 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 and labor and her feelings of joy or ambivalence with a knowledgeable and accepting woman (Fig. 8-1). Reminiscing about the pregnant woman’s early childhood and sharing the prospective grandmother’s account of her childbirth experience help the daughter 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 (Fig. 8-2).



The marital or committed relationship is not static but, instead, evolves over time. The addition of a child changes forever the nature of the bond between partners. This can be 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 individual. The sexual relationship is affected by physical, emotional, and interactional factors, including misinformation about sex during pregnancy, sexual dysfunction, and physical changes in the woman. An individual may inaccurately attribute anomalies, intellectual disability, and other injuries to the fetus and mother to sexual relations during pregnancy. Some couples fear that the woman’s genitalia will be drastically changed by the birth process. Couples may 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 may decrease, especially if she has breast tenderness, nausea, or fatigue. As she progresses into the second trimester, 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 may increase her physical discomfort and diminish her interest in sex. Partners need to feel free to discuss their sexual responses during pregnancy with each other and with their health care provider (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.” In phase 2, the woman accepts the growing fetus as distinct from herself and as a person to nurture. She can now say, “I am going to have a baby.” Attachment by a mother to her child is enhanced by experiencing a planned pregnancy, and it increases when ultrasound examination and quickening confirm the reality of the fetus. During phase 3, 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. For example, she may speculate about the child’s sex (if she has not had an ultrasound that confirms the sex) and 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 with the unborn child by talking to the fetus and stroking the mother’s abdomen, especially when the fetus shifts position. They may sing to, play music for, or read to the fetus. The fetus may have a nickname used by family members.


Parents may occasionally show or voice disappointment over the sex of the child. The parents may experience grief and a sense of loss at birth as they release their fantasized image of the child and begin to accept the real child. However, these negative responses are usually temporary. Providing an accepting environment for parental reactions facilitates the parents’ ability to move beyond disappointment to acceptance.



Preparing for Childbirth


Many women actively prepare for birth. They read books and information on various websites, view films, attend parenting classes, and talk to other women. They seek the best caregiver possible for advice, monitoring, and caring. The multipara has her own history of labor and birth, which influences her approach to preparation for this childbirth experience.


Anxiety can arise from concern about safe passage for herself and her child during the birth process (Mercer, 1995; Rubin, 1975). This concern may not be expressed overtly, but cues are given as the nurse listens to plans women make 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 by the nurse can alleviate many of these fears.


Toward the end of the third trimester, breathing is difficult and fetal movements become vigorous enough to disturb the mother’s sleep. Backaches, frequency and urgency of urination, constipation, and varicose veins can become troublesome. The bulkiness and awkwardness of her body interfere with the woman’s ability to care for other children, perform routine work-related duties, and assume a comfortable position for sleep and rest. 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 becomes physically and emotionally engrossed in the unborn child. The man 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 a 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, fantasy, great pleasure, and intense learning.



Accepting the Pregnancy


The ways fathers adjust to the parental role have 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. In this way, 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.


The man’s emotional response 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 dismay, depending on whether the pregnancy is desired, 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.


• 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 the pregnant woman and to respond supportively to her feelings of vulnerability. The partner also must 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. Direct rivalry with the fetus may be evident, especially during sexual activity. Men may protest that fetal movements prevent sexual gratification or that the fetus is watching them during sexual activity. Feelings of rivalry may be unconscious and not verbalized but 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 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 in 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 fetal movement. Calling the unborn child by name or nickname helps confirm the reality of pregnancy and promote attachment.


Men prepare for fatherhood in many of the same ways that women prepare for motherhood (i.e., by reading and 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. They may adjust work commitments or plan vacations so that they can spend time with their new family.


Nurses can help fathers identify concerns and prepare for the reality of a baby by asking questions such as:



Some fathers may not wish to answer such questions when they are asked but may need time to think them through or discuss them with their partners.


As the birth date approaches, fathers have more questions about fetal and newborn behaviors. Some fathers are shocked or amazed at the small size of the clothes and furniture for the baby. The nurse can tell the father about the unborn child’s ability to respond to light, sound, and touch and encourage him to feel and talk to the fetus. A tour of the birthing facility and an opportunity to see newborn infants or have discussions with new fathers, as in childbirth classes, may be welcomed.


Some men become involved by choosing the child’s name and anticipating the child’s sex if it is not already known. Some couples select the name of the child as early as the first month of pregnancy. Family tradition, religious customs, and the continuation of the parent’s name or names of relatives or friends are important in the selection process.



Preparing for Childbirth


The days and weeks immediately before the expected day of birth are characterized by 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 can become dissatisfied with their present living space. When possible, they tend to act on the need to alter the environment (e.g., remodeling, painting). This activity can be overt evidence of their 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 mother to the birthing 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 midwife. They fantasize different situations and plan what they will do in response to them; 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 have fears concerning safe passage of his partner and the mutilation or death of his partner or child. It is important that he verbalizes these fears; otherwise he cannot help his mate deal with her unspoken or overt 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. The tensions and apprehensions of the unprepared, unsupportive father are readily transmitted to the mother and may increase her fears.


The same fears, questions, and concerns may affect birth partners who are not the biologic fathers. Birth partners need to be kept 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 baby. Some of the factors that influence the child’s response are age, the parents’ attitudes, the father’s role, the length of separation from the mother, the hospital’s visitation policy, and how the child has been prepared for the change.


A mother with other children must devote time and energy to reorganizing her relationships with these children. She needs to prepare siblings for the birth of the baby (Fig. 8-3 and Box 8-1). She can 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 8-1   Tips for Sibling Preparation








Sibling responses to pregnancy vary with 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 the mother’s appearance and may comment, “Mommy’s fat.” The 2-year-old child’s need for sameness in the environment makes the child aware of any change. Toddlers may exhibit more clinging behavior and revert to dependent behaviors in toilet training or eating.


By age 3 or 4 years, children like to be told the story of their own beginning and accept its being compared to the present pregnancy. They like to listen to heartbeats and feel the baby moving in utero (see Fig. 8-3). 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 readying 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?” Many pregnant women with teenage children confess that their teenagers are the most difficult factor in their current pregnancy.


Late adolescents do not appear to be unduly disturbed. They realize that they soon will be gone from home. Parents usually report that late adolescents are comforting and act more like other adults than 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 30s or 40s. A mother-to-be announcing her pregnancy to her mother may be greeted by a negative response that indicates she is not ready to be a grandmother. Both daughter and mother may be startled and hurt by the response.


In some family units, expectant grandparents are nonsupportive and may 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 with the prospect of a new baby in the family. It reawakens their 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 their child’s first smiles, first words, and first steps that can be used later for “claiming” the newborn as a member of the family. Their satisfaction and that of the parents come with the realization that continuity between past and present is guaranteed.


The grandparent is the historian who transmits the family history, a resource person 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. 8-5). Other sources of information cannot replace the unique contribution that grandparents make (www.grandparents.com; www.grandparenting.org).




Care Management


The goal of prenatal care is to promote the health and well-being of the pregnant woman, her fetus, the newborn, and the family (Gregory, Niebyl, and Johnson, 2012). Major emphasis is placed on preventive aspects of care, primarily to motivate the pregnant woman to practice optimal self-management and report unusual changes early so that problems can be minimized or prevented. 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. Therefore the goals of prenatal nursing care are to promote positive pregnancy outcomes, to foster a safe birth for the infant and mother, and to promote satisfaction of the mother and family with the pregnancy and birth experience.


According to the National Center for Health Statistics, based on data from 27 states and Puerto Rice, 71% of women received prenatal care in the first trimester. Only 7% of women started prenatal care late (during third trimester) or had no prenatal care. The subgroups most likely to receive late or no prenatal care were American Indian, Alaska Native, African-American, and Hispanic (Osterman, Martin, Mathews, et al., 2011). Although women of middle or high socioeconomic status routinely seek prenatal care, women living in poverty or those who lack health insurance are not always able to use public health care services or gain access to private care. Lack of culturally sensitive care providers and barriers in communication caused by differences in language also interfere with access to care. Immigrant women from cultures in which prenatal care is not emphasized may not know to seek routine prenatal care. Thus birth outcomes in these populations are less positive, with higher rates of maternal and fetal or newborn complications. In particular, problems with low birth weight (LBW) (less than 2500 g [5.5 lb]) and infant mortality have been associated with inadequate prenatal care (Cunningham, Leveno, Bloom, et al., 2010).


Barriers to obtaining health care during pregnancy include a lack of motivation to seek care, especially for unintended pregnancies; inadequate finances; lack of transportation; unpleasant clinic personnel, facilities, or procedures; inconvenient clinic hours; child care problems; and personal attitudes (Novick, 2009; Phillippi, 2009). The availability and accessibility of prenatal care may be improved by increasing the use of advanced practice nurses in collaborative practice with physicians or midwives. A regular schedule of home visits by nurses aids in reducing barriers to care and contributes to improved maternal and infant outcomes (Agency for Healthcare Research and Quality [AHRQ] Healthcare Innovations Exchange, 2012).


The traditional model for provision of prenatal care has been used for more than a century. The initial visit usually occurs in the first trimester, with monthly visits through week 28 of pregnancy. Thereafter, visits are scheduled every 2 weeks until week 36 and then every week until birth. More recently, the trend is toward individualizing the schedule of care. Women with low-risk pregnancies may have fewer routine prenatal visits, whereas those at risk for complications may be seen more frequently than the traditional schedule (American Academy of Pediatrics [AAP] Committee on Fetus and Newborn and American College of Obstetricians and Gynecologists [ACOG] Committee on Obstetric Practice, 2012).


Group prenatal care is an alternative model to traditional care during pregnancy. In group prenatal care, 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. CenteringPregnancy (www.centeringhealthcare.org/) is a well-known model of group prenatal care that involves three components: health care assessment, education, and peer support. Most care takes place in the group setting after the initial visit and continues for ten 2-hour sessions that begin at about 16 weeks. At each meeting, the first 30 to 40 minutes consists of assessments (by the woman herself and by the health care provider) and the remaining 60 to 75 minutes is spent in group discussion of specific issues such as discomforts of pregnancy and preparation for labor and birth. Families and partners are encouraged to participate. Benefits associated with group prenatal care include improved birth outcomes such as lower rates of preterm birth, increased knowledge, improved satisfaction, and higher breastfeeding initiation rates (Herrman, Rogers, and Ehrenthal, 2012; Picklesimer, Billings, Hale, et al., 2012; Rotundo, 2011; Robertson, Aycock, and Darnell, 2009).


Prenatal care is ideally a multidisciplinary activity in which nurses work with nurse-midwives, nutritionists, physicians, 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.


In recent years, the concept of preconception care has been recognized as an important contributor to good pregnancy outcomes (see Chapter 3). If women can be taught healthy lifestyle behaviors and then practice them before conception—specifically, good nutrition, entering pregnancy with as healthy a weight as possible, adequate intake of folic acid, avoidance of alcohol and tobacco use, prevention of sexually transmitted infections (STIs) and other health hazards—a healthier pregnancy may result. Likewise, women who have health problems related to chronic diseases such as diabetes mellitus can be counseled regarding their special needs with the intent to minimize maternal and fetal complications.



Initial Visit


Once the pregnancy is confirmed and the woman’s desire to continue the pregnancy has been validated, prenatal care is begun. The assessment process begins at the initial visit and is continued throughout the pregnancy. Assessment techniques include the interview, physical examination, and laboratory tests. Because the initial visit and follow-up visits are distinctly different in content and process, they are described separately.



Interview


The pregnant woman and her partner or family members who may be present should be told that the first prenatal visit is longer and more detailed than future visits. 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.


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.


With the woman’s permission, include persons accompanying her in the initial prenatal interview (Fig. 8-6). Observations and information about the woman’s partner and/or 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).







Health History


The health history includes those physical or surgical procedures that can affect the pregnancy or that can be affected by the pregnancy. For example, a pregnant woman who has diabetes or epilepsy requires special care. Because most women are anxious during the initial interview, the nurse’s reference to cues such as a MedicAlert bracelet prompts the woman to explain allergies; chronic diseases; or medications being taken such as cortisone, insulin, or anticonvulsants.


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


Women may forget to mention chronic or handicapping conditions during the initial assessment because they have adapted to them. Special shoes or a limp may indicate the existence of a pelvic structural defect—an important consideration in pregnant women. The nurse who observes these special characteristics and sensitively inquires about them can obtain individualized data that will provide the basis for a comprehensive nursing care plan to help optimize pregnancy outcomes (Signore, Spong, Krotoski, et al., 2011). Observations are a vital component of the interview process because they prompt the nurse and the woman to focus on the specific needs of the woman and her family.



Nutritional History


The nutritional status of a pregnant woman has a direct effect on the growth and development of the fetus. A dietary assessment can reveal special diet practices, food allergies, eating behaviors, the practice of pica, and other factors related to her nutritional status (see Box 9-7). Pregnant women are usually motivated to learn about good nutrition and respond well to nutritional advice generated by this assessment.


It is essential that obese women receive counseling about weight gain, nutrition, and food choices. They should also be advised about their risk for complications for themselves and increased risk for congenital abnormalities (Davies, Maxwell, McLeod, et al., 2010). Women with a history of bariatric surgery are nutritionally at risk and should be followed closely throughout pregnancy to promote maternal and fetal well-being (Magdaleno, Pereira, Chaim, et al., 2012).



History of Use of Drugs and Herbal Preparations


A woman’s past and present use of drugs, both legal (over-the-counter [OTC], prescription, and herbal drugs; caffeine; alcohol; nicotine) and illegal (marijuana, cocaine, heroin), must be assessed because many substances cross the placenta and can harm the developing fetus. See Chapter 11 for discussion of substance abuse during pregnancy. Increasing numbers of individuals are using herbal preparations, and this includes pregnant women. Therefore it is important for health care providers to question pregnant women regarding the use of herbal preparations and document their responses.





Social, Experiential, and Occupational History


Situational factors such as the family’s ethnic and cultural background and socioeconomic status are assessed while the history is obtained. The following information may be obtained over several encounters. The woman’s perception of this pregnancy is explored by asking her such questions as:



The family support system is determined by asking her such questions as:



Other questions that should be asked include:



During interviews throughout the pregnancy, the nurse should remain alert for the appearance of potential parenting problems such as depression, lack of family support, and inadequate living conditions. The nurse must 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. It is important to ask about attitudes toward unmedicated or medicated childbirth and about her knowledge of the availability of parenting skills classes. 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, the labor and birth process, the behaviors of the newborn, the relationship with the baby’s father or partner and her family, changes in body image, and physical symptoms.


Explore attitudes concerning the range of acceptable sexual behavior during pregnancy by asking, for example, What has your family (partner, friends) told you about sex during pregnancy? The woman’s sexual self-concept is given emphasis by asking such questions as: 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?


Women should be questioned regarding their occupation, past and present, since this may adversely affect maternal and fetal health. For some women, heavy lifting and exposure to chemicals and radiation may be part of their daily work, and these activities can negatively affect the pregnancy. For others, long hours of sitting at a desk working on a computer can contribute to carpal tunnel syndrome or circulatory stasis in the legs.



History of Physical Abuse


All women should be assessed for a history of or risk for physical abuse, particularly because the likelihood of intimate partner violence (IPV) increases during pregnancy (see Chapter 3). This screening should be done at the first prenatal visit, at least once each trimester, and at the postpartum visit (American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, 2012a). It is essential that the screening is done in a safe, private setting with the woman alone. Nurses can ask the woman screening questions with routine assessments during pregnancy. Examples of questions that might be asked include:



Although visual cues from the woman’s appearance or behavior may suggest the possibility of abuse, no one profile of the battered woman exists. Identification of abuse and immediate clinical intervention that includes information about safety can result in behavior that may prevent future abuse and increase the safety and well-being of the woman and her infant. 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 constitutes a particularly difficult situation. Adolescents may be trapped in the abusive relationship because of their inexperience. Routine screening for abuse and sexual assault is recommended for pregnant adolescents. Because pregnancy in young adolescent girls is commonly the result of sexual abuse, the nurse should assess the girl’s desire to maintain the pregnancy.


Nurses should be aware that victims of human trafficking may be seen in prenatal settings because of unintended pregnancy. These women or young girls are forced or deceived into commercial sex acts (prostitution) with little or no pay. They are under strict control by their traffickers. Similar to victims of IPV, these women are likely to exhibit signs of physical abuse or neglect such as scars, bruises, burns, unusual bald patches, or tattoos that may be a sign of branding. They are likely to be accompanied by someone who never leaves them alone and speaks for them. They may not speak English and may lack identification documents. If the woman is alone, she may have her cell phone on and in speaker mode so that the person on the other end can hear everything that is said during the visit. Nurses and other health care providers must be creative in getting the woman alone for questioning. Strategies might include sending the other person to the front desk to fill out paperwork, interviewing the woman in the restroom, or telling her she needs to go for testing and cannot take her cell phone. With the consent of suspected or confirmed victims of human trafficking, intervention plans can be developed. An excellent resource is the National Human Trafficking Resource Center (1-888-373-7888) (Dovydaitis, 2010; Tracy and Konstantopoulos, 2012).




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 during the examination and an explanation of the procedure itself. The interaction requires an unhurried, sensitive, and gentle approach with a matter-of-fact attitude.


The physical examination begins with assessment of vital signs, including blood pressure (BP), height, and weight (for calculation of body mass index [BMI]) (see Chapter 9). The bladder should be empty before pelvic examination.


Each examiner develops a routine for proceeding with the physical examination; most choose the head-to-toe progression. Heart and lung sounds are evaluated, and extremities are examined. The skin is assessed for changes in pigmentation, rashes, and edema. Distribution, amount, and quality of body hair are of particular importance because the findings reflect nutritional status, endocrine function, and attention to hygiene. The thyroid gland is assessed carefully, as are the breasts and abdomen. The height of the fundus is noted if the first examination occurs after the first trimester of pregnancy. During the examination, the examiner must remain alert to the woman’s cues that give direction to the remainder of the assessment and that indicate imminent untoward response, such as feeling lightheaded or dizzy. See Chapter 3 for a detailed description of the physical examination.


Whenever a pelvic examination is performed, the tone of the pelvic musculature and the woman’s knowledge of Kegel exercises are assessed. Particular attention is paid to the size of the uterus because this is an indication of the duration of gestation. The nurse present during the examination can coach the woman at this time in breathing and relaxation techniques as needed. One vaginal examination during pregnancy is recommended; another is usually not done unless indicated for medical reasons.



Laboratory Tests


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


Specimens are collected at the initial visit so that any abnormal findings can be treated. Blood is drawn for a variety of tests (Table 8-1). A sickle cell screen is recommended for women of African, Asian, or Middle Eastern heritage. Testing for antibody to the human immunodeficiency virus (HIV) is strongly recommended for all pregnant women; this testing must be voluntary and without coercion (ACOG Committee on Obstetric Practice, 2011a; Centers for Disease Control and Prevention [CDC], 2010) (Box 8-2). The folate level is measured when indicated. Cystic fibrosis (CF) carrier screening tests should be offered to all pregnant women; if the woman is a CF carrier, the father of the baby should be tested. Concurrent testing is recommended if there are time constraints related to prenatal diagnostic evaluation (ACOG Committee on Genetics, 2011). A urine specimen is collected for cultures and metabolic function tests. A purified protein derivative tuberculin test may be administered to assess exposure to tuberculosis. During the pelvic examination, cervical and vaginal smears can be obtained for cytologic studies and for diagnosis of infection (e.g., chlamydia, gonorrhea).



Box 8-2


Human Immunodeficiency Virus 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: prenatal and perinatal human immunodeficiency virus testing—expanded recommendations, Obstet Gynecol 104(5 Part 1):1119–1124, 2011; AWHONN: HIV screening procedures for pregnant women and newborns—policy position statement, Washington, DC, 2008, Author; Burr C: Reducing maternal-infant HIV transmission. In Coffey S, editor: Guide for HIV/AIDS clinical care, Rockville, MD, 2011, US 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: Sexually transmitted diseases treatment guidelines, Morb Mortal Wkly Rep 59(RR12):1–110, 2010.



TABLE 8-1


LABORATORY TESTS IN THE PRENATAL PERIOD




















































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

BUN, Blood urea nitrogen; ECG, electrocardiogram; FTA-ABS, fluorescent treponemal antibody absorption test; GBS, group B streptococcus; hCG, human chorionic gonadotropin; HIV, human immunodeficiency virus; HPV, human papilloma virus; RBC, red blood cell; RPR, rapid plasma reagin; VDRL, Venereal Disease Research Laboratories; WBC, white blood cell.


*With patient permission.


Recognition of risk factors during pregnancy may indicate the need to repeat some tests at other times. For example, exposure to tuberculosis or an STI would necessitate repeat testing. STIs are common in pregnancy and may have negative effects on mother and fetus (see Table 4-5 on p. 98). Careful assessment and thorough screening are essential.



Follow-Up Visits


Monthly visits are scheduled routinely during the first and second trimesters, although additional appointments may be made as the need arises. During the third trimester, the possibility for complications increases and closer monitoring is necessary. Starting with week 28, visits are scheduled every 2 weeks until week 36; then visits are scheduled every week until birth unless the health care provider individualizes the schedule. Individual needs, complications, and risks of the pregnant woman may warrant visits more or less often. The pattern of interviewing the woman first and then assessing physical changes and performing laboratory tests is maintained.


In prenatal care models that use a reduced-frequency screening schedule or in group prenatal care models such as CenteringPregnancy, the timing of follow-up visits will be different but assessments and care will be similar.



Interview


Follow-up visits are less intensive than the initial prenatal visit. At each of these follow-up visits, the woman is asked to summarize relevant events that have occurred since the previous visit. She is asked about her general emotional and physical well-being, complaints or problems, and questions she may have. Personal and family needs are identified and explored.


A woman’s emotional state can affect her and her family’s general well-being. Therefore the nurse asks whether the woman has had any mood swings, reactions to changes in her body image, bad dreams, or worries. Positive feelings (her own and those of her family) are also noted. The reactions of family members to the pregnancy and the woman’s progression through the developmental tasks of pregnancy are also assessed and recorded.


During the third trimester, current family situations and their effect on the woman are assessed (e.g., the response of partner, siblings, and grandparents to the pregnancy and the coming child). The nurse needs to assess the parents’ understanding of the following: the warning signs that indicate emergencies such as bleeding and abdominal pain, the signs of preterm and term labor, the labor process and anxieties about labor, fetal development, and methods to assess fetal well-being. The nurse should ascertain whether the woman is planning to attend childbirth preparation classes and what she knows about the control of discomfort during labor. If she is having a home birth, she should be queried as to whether all the necessary supplies have been obtained.


A review of the woman’s physical systems is appropriate at each visit, and any suggestive signs or symptoms are assessed in depth. Discomforts reflecting adaptations to pregnancy are identified. Special inquiries are made about possible infections (e.g., genitourinary tract, respiratory tract). The woman’s knowledge of and success with self-management measures are assessed, as well as outcomes of prescribed therapy.

Sep 16, 2016 | Posted by in NURSING | Comments Off on Nursing Care of the Family During Pregnancy
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