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Specific Objectives:
1. Identify the factors that influence the woman’s attitude
towards pregnancy.
2. Identify the emotional responses of the woman to pregnancy.
3. Describe the psychological tasks the pregnant woman has to
accomplish in each trimester.
4. Know the discomforts commonly felt during the each trimester
of pregnancy.
5. Identify teratogenic factors and their effects to the fetus.
6. Recognize the danger signs of pregnancy.
7. Plan nursing care related to health promotion, discomforts and
danger signs related to pregnancy and limitation of exposure
to teratogens
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 Factors that Influence the Woman’s
Attitude towards Pregnancy
1. Social
➢ Personal experiences
➢ Experiences of friends & relatives
2. Cultural
➢ Beliefs
➢ Taboos
3. Family
➢ The family in which the woman was raised.
4. Individual
➢ Woman’s ability to cope with or adapt to stress
➢ Ability to adapt to being a mother
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 Emotional Responses
1. Ambivalence
2. Grief
3. Narcissism
4. Introversion vs. Extroversion
5. Body Image & Boundary
6. Stress
7. Couvade Syndrome
8. Emotional Lability
9. Changes in Sexual Desire
10. Changes in the Expectant Family
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 Psychological Tasks the Pregnant Woman
has to Accomplish in each Trimester
▪ FIRST TRIMESTER  Common reaction is
Task: Accepting the ambivalence
Pregnancy
 Begins to imagine herself
▪ 2nd TRIMESTER as a mother (anticipatory
Task: Accepting the Baby role-playing)
 Woman feels fetal
movement
▪ 3rd TRIMESTER  “nest-building” activities
Task: Preparing for the  Role-playing
Baby & Parenthood
 fantasizing
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 Health Promotion
1. Self-care needs
1) Bathing
▪ daily tub baths or showers are recommended.
▪ heat exposure for a lengthy time could lead to
hyperthermia in the fetus and birth defects (specifically
esophageal atresia, omphalocele, and gastroschisis)
2) Breast care
 wear a firm, supportive bra with wide straps
 Teach her to wash her breasts with clear tap water (no
soap, because that could be drying and cause her nipples
to crack) daily to remove the colostrum and reduce the
risk of infection.
 Health Promotion
1. Self-care needs
3) Dental care
 There is a strong correlation between poor oral health
and preterm birth, so maintaining good oral health
during pregnancy is important
 When bacteria in the mouth interact with sugar, this
lowers the pH of the mouth, creating an acid medium
that can lead to etching or destruction of the enamel of
teeth
 Health Promotion
1. Self-care needs
4) Perineal hygiene
 Maintain good perineal hygiene.
 Caution them to always wipe front to back after voiding to
prevent bringing contamination forward from the rectum.
5) Clothing
 Women should be cautioned to avoid garters, extremely firm
girdles with panty legs, and knee-high stockings during pregnancy
because these may impede lower extremity circulation.
 Suggest wearing shoes with a moderate-to-low heel to minimize
pelvic tilt and possible backache as well as to reduce the risk of
falling.
 Health Promotion
2. Sexual activity
 Women who have a history of previous preterm birth should
consult their obstetric provider for specific advice.
 Women whose membranes have ruptured or who have vaginal
spotting should be advised against coitus until examined by
their primary care provider to prevent possible infection or
complications.
 Changes in sexual position may be needed to increase
comfort.
 Health Promotion
3. Exercise
 220 – 20 (age of woman) = 200 x 70% = 140 bpm
 Walking is the best exercise during pregnancy
 women should be encouraged to take a walk daily unless
inclement weather, many levels of stairs, or an unsafe
neighborhood are contraindications.
 Yoga is also a good exercise as long as positions are limited to those
in which pregnant women are able to maintain balance
 Swimming is a good activity for pregnant women and, like bathing, is
not contraindicated as long as membranes are intact.
 Please refer to the GUIDELINES FOR EXERCISE IN PREGNANCY p. 261
 Health Promotion
4. Sleep
 growth hormone secretion is at its highest level—that is, during
sleep.
 A good resting or sleeping position is a left-sided Sims position,
with the top leg forward
5. Employment
 May continue to work unless a woman’s job involves exposure to
toxic substances, lifting heavy objects, other kinds of excessive
physical strain, long periods of standing or sitting, or having to
maintain body balance.
 please refer to GUIDELINES FOR PREGNANT WOMEN
WORKING OUTSIDE THEIR HOME p. 263
6. Travel
Health Promotion
 Advise a woman who is taking a long trip by automobile to plan
for frequent rest or stretch periods.
 Preferably every hour, but at least every 2 hours, she should get out of the
car and walk a short distance.
 This break relieves stiffness and muscle aches and improves lower
extremity circulation, helping prevent varicosities, hemorrhoids, and
thrombophlebitis.
 Caution her not to eat unwashed fruits or vegetables or raw meats and not to
drink unpurified water.
 she should make arrangements to visit a healthcare provider in that area so
she can keep the schedule of her regular prenatal visits. Also, make certain
she has enough of her prescribed vitamin supplement plus adequate
prescriptions for refills as necessary.
 Minor Body Changes of Pregnancy
(1st Trimester)
1. Breast tenderness - wide strap bra
2. Palmar erythema (palmar pruritus)
 due to increased estrogen
 may apply calamine lotion
3. Constipation
4. Nausea, vomiting and pyrosis (heartburn)
5. Fatigue
 due to increased metabolic requirement
 increase amount of rest & sleep
 Minor Body Changes of Pregnancy
st
(1 Trimester)
6. Muscle cramps
 dorsiflex foot; elevate LE freq.,
 Due to decreased serum calcium levels, increased serum
phophorus levels, and possibly, interference with circulation.
 Take a calcium supplement
 Take magnesium lactate or citrate once in the morning and again
in the evening as these bind phosphorus in the intestinal tract
and thereby lower its circulating level
7. hypotension
 Minor Body Changes of Pregnancy
st
(1 Trimester)
8. Varicosities - elevate leg 15-20 min 2x/day
9. Hemorrhoids
10. Heart palpitations
 due to increased blood volume
 Gradual, slow movements will help prevent this from happening.
11. Frequent urination
 void as often as necessary, as urine stasis can lead to infection.
 perform Kegel exercises are exercises designed to strengthen the
pubococcygeal muscles. Each is a separate exercise and should be done
about three times per day.
12. Abdominal discomfort
13. leukorrhea
 Minor Body Changes of Pregnancy
Late Pregnancy
1. Backache – pelvic rock/tilt; squat instead of bend
2. Headache – due to expanding blood volume
3. Dyspnea
4. Ankle edema – due to general fluid retention
5. Braxton Hicks contractions
 Complications of Pregnancy
(danger signs)
1. Vaginal bleeding
▪ all women with spotting need further evaluation.
2. Persistent vomiting
▪ Persistent or extended vomiting depletes the nutritional supply
available to a fetus and thus is a danger to the pregnancy.
3. Chills and fever or pain on urination
▪ May indicate an intrauterine infection, a potentially serious complication
for both a woman and a fetus.
▪ Pain on urination is a symptom of a urinary infection, and are associated
with preterm birth.
 Complications of Pregnancy
(danger signs)
4. Sudden escape of clear fluid from the vagina
▪ means the membranes have ruptured
▪ umbilical cord may prolapse.
▪ If the fetal head then presses on the misplaced cord,
oxygenation can be compromised and the fetus will
be in immediate and grave danger.
▪ Urine can be identified by Nitrazine paper as urine
is acidotic (the test strip turns yellow), whereas
amniotic fluid is alkaline (the strip turns blue).
 Complications of Pregnancy
(danger signs)
5. Abdominal or chest pain
▪ Abdominal pain could be a sign of
1) tubal (ectopic) pregnancy,
2) separation of the placenta (abruptio placenta)
3) preterm labor (regular contractions, cervical changes)
4) appendicitis
5) ulcer, or pancreatitis.
▪ Chest pain and shortness of breath may indicate a pulmonary
embolus, a complication that can follow thrombophlebitis.
6. Increase or decrease in fetal movement
*Sandovsky method= Normal: 10-12x/hr.
 Complications of Pregnancy
(danger signs)
7. Gestational hypertension.
▪ usually after 20 weeks of pregnancy.
▪ S/Sx:
1) Rapid weight gain
❖ Over 2 lbs/week in 2nd tri, 1 lb/week 3rd tri (Normal: 3-12-12)
2) Swelling of the face or fingers
3) Flashes of light or dots before the eyes
 Complications of Pregnancy
(danger signs)
7. Gestational hypertension.
4) Dimness or blurring of vision
5) Severe, continuous headache
▪ may signal cerebral edema or acute hypertension.
6) Decreased urine output (Normal: 30 ml/hr)
7) Right upper quadrant pain unrelated to fetal position
▪ ischemia of the liver
8) Blood pressure increased above 140/90 mmHg
 Preventing Fetal Exposure to
TERATOGENS
What is a teratogen?

Is any factor, chemical or physical, that

adversely affects the fertilized ovum, embryo
or fetus.

Is any agent that can induce or increase the

incidence of a congenital malformation.
 Effects of teratogens on the Fetus
 Factors that influence the amount of damage a teratogen can cause:
1) Strength of teratogens (ex: radiation)
2) Timing of the teratogenic insult
▪ If a teratogen is introduced before implantation, for example, either
the zygote is destroyed or it appears unaffected.
▪ If the insult occurs when the main body systems are being formed (in
the second to eighth weeks of embryonic life), a fetus is very
vulnerable to injury.
▪ During the last trimester, the potential for harm again decreases
because all the organs of a fetus are formed and are merely maturing.
 Effects of teratogens on the Fetus
 Factors that influence the amount of damage a teratogen
can cause:
3) Teratogen’s affinity for specific body tissues.
▪ Lead and mercury, for example, attack and disable nervous
tissue.
▪ Thalidomide (Immunoprin), originally used to treat nausea
in pregnancy, is now prescribed for cancer therapy, and it
may cause limb defects.
▪ Tetracycline (Apo-Tetra), a common antibiotic, causes
tooth enamel deficiencies, and possibly, long bone
deformities.
▪ The rubella virus affects many organs, with the eyes, ears,
heart, and brain the four most commonly attacked
 Teratogenic Maternal Infections
 Teratogenic maternal infections involve viral,
bacterial, or protozoan organisms, which cross the
placenta from mother to fetus.
 Malaria
 caused by intraerythrocytic protozoa of the
genus Plasmodium transmitted to humans by the
bite of an infected female Anopheles mosquito.
 Healthcare providers can contract it from infected
blood products.
 During pregnancy, women can transmit malaria to a
fetus.
 Teratogenic Maternal Infections
 Malaria
 A number of drugs, such as chloroquine (Aralen)
in the first trimester and mefloquine (Lariam) in
the second or third trimesters, are helpful.
 Women who will be visiting an area known to be
epidemic for malaria can begin treatment as
prophylaxis up to 2 weeks before travel.
 Teratogenic Maternal Infections
When newborns are tested to see if antibodies
against the common infectious teratogenic
diseases are present, the test is described
collectively under the umbrella term TORCH:
 Toxoplasmosis
 Rubella
 Cytomegalovirus
 Herpes simplex virus
 Note: some sources identify the O with
“other infections”, which include syphilis, HBV (Hep B
virus), and HIV.
 Toxoplasmosis
 A protozoan infection, is spread most commonly through contact
with uncooked meat, although it may also be contracted through
handling cat stool in soil or cat litter.
 If the infection crosses the placenta, the infant may be born with
CNS damage, hydrocephalus, microcephaly, intracerebral
calcification, & retinal deformities.
 Pyrimethamine, an antifolic acid drug and an antiprotozoal agent
is used cautiously early in pregnancy to prevent reducing folic
acid levels.
 Rubella
 Fetal damage from maternal infection with rubella (german measles)
includes:
1) deafness
2) mental and motor changes
3) Cataracts
4) cardiac defects(most commonly patent ductus arteriosus & pulmonary
stenosis)
5) retarded intrauterine growth(small for gestational age)
6) thrombocytopenic purpura (patches of purplish discoloration)
7) dental & facial clefts, such as cleft lip & palate (Lee& Bowden, 2000)

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 A woman who is not immunized before pregnancy cannot be
immunized during pregnancy.
▪ because the vaccine contains a live virus that would have effects
similar to those occurring with a subclinical case of rubella.
 After a rubella immunization, a woman is advised not to become
pregnant for 3months until the rubella virus is no longer active.
▪ all pregnant women should avoid contact with children with
rashes.
▪ all pregnant women should avoid contact with children with
rashes.
▪ Nurses who care for pregnant women or newborns should receive
immunization against rubella
 All women w/ low rubella titers should be immunized to provide
protection against rubella in future pregnancies

▪ A titer greater than 1:8 suggests immunity to the disease.

▪ A titer of less than 1:8 suggests a woman is susceptible to viral
invasion.
▪ A titer that is greatly increased over a previous reading or is initially
extremely high suggests a recent infection has occurred.
 Cytomegalovirus (CMV)
 Cytomegalovirus (CMV), a member of the HSV family.
 can cause extensive damage to a fetus while causing few
symptoms in a woman (Martin & Satin, 2015).
 not sexually transmitted but spreads from person to person by
droplet infection such as occurs with sneezing.
 Cytomegalovirus (CMV)
 If a woman acquires a primary CMV infection during
pregnancy and the virus crosses the placenta
 the infant may be born with severe neurologic challenges (e.g.,
hydrocephalus, microcephaly, or spasticity) or with eye damage
(e.g., optic atrophy or chorioretinitis), hearing impairment, or
chronic liver disease.
 The newborn’s skin may be covered with large petechiae (i.e.,
“blueberry-muffin” lesions).
 Cytomegalovirus (CMV)
 Because a woman has almost no symptoms, she may not even
be aware she contracted an infection.
 Diagnosis in the mother or infant can be established by the
isolation of CMV antibodies in blood serum (BLOOD
CULTURE).
 Unfortunately, there is NO TREATMENT for the infection even if
it presents in the mother with enough symptoms to allow
detection.
 Cytomegalovirus (CMV)

 Because there is no treatment or vaccine for the disease, routine

screening for CMV during pregnancy is not recommended.
▪ Advise women to wash hands thoroughly before eating
▪ avoid crowds of young children at daycare or nursery school
settings to help prevent exposure (Drew, Stapleton, Abu, et al.,
2015).
 Herpes Simplex Virus (Genital
Herpes Infection)
 The virus spreads into the bloodstream (viremia) and
crosses the placenta to the fetus.
 1st trimester
 congenital anomalies or spontaneous miscarriage may
occur.

 2nd or 3rd
 high incidence of premature birth, intrauterine growth
retardation, & continuing infection of the newborn
birth.
 Herpes Simplex Virus (Genital
Herpes Infection)
 If genital lesions are present at the time of birth, however, a
fetus may contract the virus from direct exposure during birth.
 Cesarean birth is usually advised to reduce the risk of this route of
infection.
 This awareness of the placental spread of HSV has increased
the importance of obtaining information about exposure to HSV
or any painful perineal or vaginal lesions that might indicate this
infection at prenatal visits through conscientious history taking.
 Herpes Simplex Virus (Genital
Herpes Infection)
 Acyclovir (Zovirax) or valacyclovir (Valtrex) can both
be safely administered to women who develop lesions
during pregnancy as well as to their newborns at birth
(Groves, 2016).
 Either drug is recommended daily as prophylaxis at 36
weeks of pregnancy to prevent a lesion at the time of birth.
 The primary mechanism for protecting a fetus, however, is
disease prevention.
 Urging women to practice safer sex is important to lessen
their exposure to this and other sexually transmitted
infections.
 Other Viral Diseases
 Syphilis
 sexually transmitted infection
 Treponema Pallidum cannot cross the placenta when
cytotrophoblast layer of chorionic villi is still intact.
 this layer atrophies at 16th – 18th week and treponema
pallidum can then cross the placenta and cause extensive
damage.
 For these reasons, serologic screening (either by a venereal
disease research laboratory [VDRL] or a rapid plasma reagin
[RPR] test) is done at a first prenatal visit;
 The test may then be repeated again close to term (the eighth
month) if recent exposure is a concern.
 Other Viral Diseases
 Syphilis
 If treated with benzathine penicillin in the 1st trimester,
fetus is rarely affected.
 If left untreated beyond 18th week:
 Hearing impairment

 Cognitive challenge

 Osteochondritis

 Fetal death
 Other Viral Diseases
 Syphilis
 Even when a woman has been treated with antibiotics, the
serum titer remains high up to 200 days;
 an increasing titer suggests reinfection has occurred.
 In an infant born to a woman with syphilis, the serologic
test for syphilis may remain positive for up to 3 months
even though the disease was treated during pregnancy.
 Other Viral Diseases
 Syphilis
 The newborn with congenital syphilis may have:
 congenital anomalies
 extreme rhinitis (sniffles)
 characteristic syphilitic rash, all of which identify the baby as
high risk at birth (Akahira-Azuma, Kubota, Hosokawa, et al.,
2015).
 When the baby’s primary teeth come in, they are often oddly
shaped (i.e., Hutchinson teeth).
 Other Viral Diseases
 Syphilis
▪ As with all sexually transmitted infections, prevention through
safer sex practices is key.
 Rubeola (measles), coxsackievirus (human enterovirus
A,B,C), infectious parotitis (mumps), varicella
(chickenpox), poliomyelitis, influenza, and viral
hepatitis all may be teratogenic.
▪ Women are advised to be vaccinated against influenza before
pregnancy.
 Other Viral Diseases
 If parvovirus B19, the causative agent of erythema
infectiosum (also called fifth disease) and a common viral
disease in school-age children, contracted during
pregnancy:
▪ it can cross the placenta and attack the red blood cells of the
fetus.
 Infection with the virus during early pregnancy
▪ associated with fetal death.
 If the infection occurs late in pregnancy
▪ the infant may be born with severe anemia and congenital
heart disease (American College of Obstetricians and
Gynecologists, 2015).
 Other Viral Diseases
 Lyme Disease
 a multisystem disease caused by the spirochete Borrelia Burgdorferi, is
spread by the bite of a deer tick.
 Signs/symptoms:
1) Erythema chronicum migrans (large, macular lesions with a clear
center)
2) Pain in large joints

3) Spontaneous miscarriage

4) Severe congenital anomalies

▪ Treatment:
1) Tetracycline & doxycycline (for non-pregnant)
2) Penicillin (for pregnant)
 Infection that cause illness at birth
 gonorrhea, candidiasis, chlamydia, stretococcus B, and
hepatitis B infections

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 Potential Teratogenicity of Vaccines
 Live virus vaccines such as:
 Measles
 Mumps
 rubella and
 Oral poliomyelitis (sabin type)

 These are contraindicated during pregnancy

because they may transmit the viral infection to
the fetus.
 Teratogenicity of Drugs
 2 principles related to drug intake during pregnancy:

 Any drug or herbal supplement, under certain circumstances,

may be detrimental to fetal welfare.

❖ duringpregnancy, women should not take any drug or

supplement not specifically prescribed by their physician or nurse
midwife.

 A woman of childbearing age and ability should take no drugs

other than those prescribed by the physician or nurse midwife
to avoid exposure to a drug should she become pregnant.
 Teratogenicity of Alcohol
 Alcohol is a common drug abused by women of childbearing age. Infants
born to alcoholic mothers demonstrate prenatal and postnatal growth
deficiency, mental retardation, and other malformations.
 Fetuses cannot remove breakdown products of alcohol from their body
leading to vit. B deficiency and neurologic damage.
 There are subtle but classical facial features associated with fetal alcohol
syndrome including short palpebral fissures, maxillary hypoplasia, a
smooth philtrum, and congenital heart disease.
 Even moderate alcohol consumption consisting of 2 to 3oz. of hard liquor
per day may produce the fetal alcohol effects.
 Teratogenicity of Cigarettes
 Growth retardation
 Sudden infant death syndrome (Pollack, 2001)
 Low birth weight in infants of smoking mothers results from
vasoconstriction of the uterine vessels, an effect of nicotine that
limits the blood supply to the fetus.
 Inhaled carbon monoxide is another contributing factor.
 Reducing the number of cigarettes smoked per day should help diminish
adverse effects on the fetus.
 Environmental Teratogens
 Metal and chemical hazards
 ex: pesticides& carbon monoxide
 Radiation
 has been proven to be a potent teratogen to unborn children
because of high proportion of rapidly growing cells present.
 Hyperthermia & Hypothermia
 (hyper) maybe detrimental to growth because it interferes
with cell metabolism
 (hypo) the effects is not well known.
 Teratogenicity of Maternal Stress
 Emotionally disturbed pregnancy, once filled with anxiety and
worry beyond the usual amount could produce physiologic
changes through its effect on the sympathetic division of the
autonomic nervous system.
 Primary changes includes increase in heart rate, constriction of
the peripheral blood vessels, a decrease in gastrointestinal
motility, & dilation of coronary blood vessels (the fight-or-flight
syndrome)
 The constriction of uterine vessels could interfere with the blood
and nutrient supply to the fetus.