Nursing Care of the

Family
During Pregnancy
Chapter 14
Learning Objectives

 Describe strategies for confirming pregnancy and estimating the date of birth.
 Summarize the physical, psychosocial, and behavioral changes that usually
occur as the expectant mother and other family members adapt to pregnancy.
 Evaluate 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 initial and follow-up visits during pregnancy.
Learning Objectives (Cont.)

 Select the typical nursing assessments, diagnoses, interventions, and methods

of evaluation in providing care for the pregnant woman.
 Plan education needed by pregnant women to understand and manage
physical discomforts related to pregnancy and to recognize signs and
symptoms of potential complications.
 Evaluate the effect of culture, age, parity, and number of fetuses on the
response of the family to the pregnancy and on the prenatal care provided.
 Compare the options for health care providers and birth setting choices that
are available.
 Nursing Care during Pregnancy
 Prenatal period
 Periodof physical and psychologic preparation for birth
and parenthood
 Opportunity for nurses and members of health care
team to influence family health
 Healthy women seek care and guidance
 Health promotion interventions can affect
well-being of woman, child, and rest of family
Nursing Care during Pregnancy

 Pregnancy
 Spans 9 months
 10 lunar months of 28 days (280 days total)
 Trimesters

 First: weeks 1 through 13

 Second: weeks 14 through 26
 Third: weeks 27 through 40
Diagnosis of Pregnancy

 Signs and symptoms

 Presumptive indicators
Missed menstrual period
Home pregnancy test positive
Amenorrhea, nausea, vomiting, breast
tenderness, urinary frequency, fatigue
(morning sickness)
Quickening (perception of fetal movement)
Diagnosis of Pregnancy

 Signs and symptoms (cont’d)

 Probable indicators
Uterine enlargement
Braxton Hicks contractions
Uterine souffle
Ballotement
Positive pregnancy test
Diagnosis of Pregnancy

 Signs and symptoms (cont’d)

 Positive indicators
Presence of fetal heartbeat distinct from mother’s
Fetal movement felt by someone other than mother
Visualization (e.g., ultrasound examination)
Estimating Date of Birth

 Estimated date of birth (EDB)

 Older terms
 Estimated date of delivery (EDD)
 Estimated date of confinement (EDC)
 Ultrasound
 Standard procedure for determining the gestational age of the fetus
 Naegele’s rule to calculate EDB
 Assumes that the woman has a 28-day cycle and that fertilization occurs
on the 14th day
 After determining the first day of the LMP, subtract 3 calendar months and
add 7 days
Adaptation to Pregnancy

 Maternal adaptation
 Accepting the pregnancy
 Identifying with the mother role
 Reordering personal relationships
 Establishing relationship with fetus: attachment process of the
mother
 Phase 1: She accepts the biologic fact of pregnancy
 Phase 2: She accepts the growing fetus as distinct from herself
 Phase 3: She prepares realistically for the birth and parenting of
the child
 Preparing for childbirth
Adaptation to Pregnancy (Cont.)

 Paternal adaptation
 Accepting the pregnancy
 Couvade syndrome
 Developmental tasks experienced by the expectant father
 Announcement phase
 Moratorium phase
 Focusing phase
 Identifying with the father role
 Reordering personal relationships
 Establishing relationship with the fetus
 Preparing for birth
Adaptation to Pregnancy (Cont.)

 Adaptationto parenthood for the

nonpregnant partner
 Sibling adaptation
Depends on age and dependency needs
 Grandparent adaptation
Sibling Adaptation

 Sharing the spotlight with a new brother or sister may be

the first major crisis for a child
 Older child often experiences a sense of loss or feels jealous
at being “replaced” by the new baby
 Factors that influence the child’s response are age, the
parent’s 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
 Mother with other children must devote time and energy to
reorganizing her relationship with these children
 She needs to prepare siblings for the birth of the baby
Grandparent Adaptation

 Expectant grandparenthood can represent a maturational

milestone for the parent of an expectant parent
 Grandparents describe having a grandchild as the best
thing that ever happen to them
 Grandparents, when the mother is a young adolescent or
for other reasons such as substance-abusing mother; the
grandchild may mean assuming care and raising another
child when they thought childrearing was over
 Grandparent is the historian who transmits the family
history
 Role model and support person
Care Management

 Purpose of prenatal care is to identify

existing risk factors and other deviations
from normal
 Emphasis on preventive care and optimal
self-care
 Prenatalcare is sought routinely by women
of middle or high socioeconomic status
Care Management

 Women in poverty or lacking health insurance may not

have access to public or private care
 Lack of culturally sensitive care and communication
interferes with access to care
 Immigrant women may not seek prenatal care
 Birth outcomes are less positive, with higher rates
of maternal and newborn complications
 Problems with LBW and infant mortality associated with
inadequate prenatal care
Care Management

 Barriers to obtaining prenatal care include:

 Inadequate numbers of providers
 Unpleasant facilities or procedures
 Inconvenient clinic hours
 Distance to facilities
 Lack of transportation
 Fragmentation of services
 Inadequate finances
 Personal and cultural attitudes
Care Management

 Effectiveness
of home visiting by nurses
during pregnancy has been validated
 Current
model of prenatal care used for
more than a century
Model is being questioned, and tendency
to fewer visits with women at low risk for
complications
 Care Management
 Initial visit
 Prenatal interview
 Reason for seeking care
 Current pregnancy
 Childbearing and female reproductive history
 Health history
 Nutritional history
 History of drug and herbal preparation use
 Family history
 Social, experiential, occupational history
Schedule of Prenatal Visits

1 X a month until 28th week

Every 2 weeks until 36th week
Weekly from 37th until delivery
Lab Tests

 PPD
 Hepatitis B
 Cervical cytology and screening for
infection - Chlamydia gonorrhea
 RPR/VDRL – HIV recommended
 CBC, Blood type and Rh-factor, antibody
screen. Tests for sickle cell, Folacin levels,
Rubella
Fundal Height

 Measurement of the height of the uterus above the

symphysis pubis, is used as one indicator of fetal growth
 Measurement also provides a gross estimate of the
duration of pregnancy
 Second and third trimester (weeks 18 to 30) the height of
the in centimeters is approximately the same as the
number of weeks gestation
 Measurement of fundal height may aid in the
identification of high risk factors
 Stable or decreased fundal height may indicate the
presence of IUGR
 Excessive increase could indicate the presence of
multifetal, gestation, or hydramnios
Care Management

 Assessment (cont’d)
 Follow-up visits
Interview
Physical examination
Fetal assessment
Fundal height
Gestational age
Health status
Detecting Fetal Heartbeat
Gestational Age

 Determined from the menstrual history, contraceptive

history, and pregnancy results
 Findings obtained from the clinical evaluation:
 First uterine size estimate, date and size
 Fetal heart rate first heard: date, method (Doppler,
stethoscope, fetoscope)
 Date of quickening
Gestational Age

 Current fundal height, estimated fetal weight

(EFW)
 Current week of gestation by history of LMP or
ultrasound examination (or both)
 Ultrasound examination: date, week of gestation,
biparietal diameter (BPD)
 Reliability of dates
A nurse is performing an assessment on a client who is 30 weeks’
gestation. The nurse measures the fundal height in centimeters and
expects the findings to be which of the following?

 1. 22 cm
 2. 28 cm
 3. 30 cm
 4. 40 cm
Care Management

 Assessment
 Follow-up visits (cont’d)
 Fetal assessment
 Laboratory tests
 Multiple-marker or triple-screen blood test
 Other blood tests (RPR/VDRL, CBC, anti-Rh)
 Other tests
 Ultrasonography

 Amniocentesis
Care Management

 Plan of care and implementation

 Care paths
 Education for self-care
 Nutrition

 Personal hygiene
 Prevention of urinary tract infections
 Kegel exercises
 Preparation for breastfeeding newborn
 Dental health
Self Care Education

 Nutrition
 Personal hygiene
 Prevention of Urinary tract Infections
 Kegal exercises
 Dental Care
 Posture and body mechanics
 Exercise
 Rest and relaxation
Self Care Education

 Posture and body mechanics

 Rest and relaxation
 Employment
 Clothing
 Travel
 Medications and herbal preparations
 Immunizations
Danger Signs in Pregnancy

 Vaginal Bleeding or drainage

 Abdominal Pain
 Headache/Blurred vision
 Edema of hands or face
 Excessive Nausea and vomiting
 Excessive weight gain
 Excessive or Decreased fetal activity
Rest, recreation and Sleep

Napping for 30 min in am and pm.

Beneficial
Breast Care

 Colostrum secreted early in pregnancy

 Bathe breasts with clean washcloth and warm
water
 Avoid- Soap. Alcohol and other drying cleansers
 Breast Support
 Well-fitted bra
 cup large enough to cover all breast tissue
 Large breasts - wide cotton shoulder straps
Bowel Habits

 Prevent Constipation by
 Drinking large amounts of fluid
 Dietcontaining fresh fruit raw veg, and whole grain
breads and bran
 Citracel or Metamucil add bulk to stool
 Stool softeners
MOM

dioctyl sodium sulfosuccinate

Hemorrhoids

 Prevent constipation
 If protruding gently push back into rectum
 Knee chest position
 Icebagor cold compresses with witch hazel or
Epsom salts
 Sitz bathes
 Kegel Exercise
Travel

 Avoid if
 any hx of vag. Bleeding, PIH, multiple gestations, or
last weeks of pregnancy
 Flying recommended for -Long distances
 Drink plenty of fluids
 Automobile
 Take rest periods every hour
 Seat belts
Lap belt Under abdomen
shoulder belt - above the uterus and below the neck
Care Management

 Plan of care and implementation

 Care paths
Education for self-care (cont’d)
Immunizations

Alcohol, cigarettes, and other substances

Normal discomforts
Recognizing potential complications
Printed list of signs and symptoms
Emergency telephone numbers
Immunizations

 Tetanus-diphtheria-acellular-pertussis (TDAP)-should be
administered between 27 and 36 weeks of pregnancy
 Recombinant hepatitis B
 Influenza (inactivated) vaccine-all women who are
pregnant during the influenza season (November through
March) should be offered the influenza vaccine
Care Management

 Assessment
 Education for self-care (cont’d)
Recognizing preterm labor
After the 20th week
Before 37th week of pregnancy
Uterine contractions, if untreated, cause cervix
to open earlier, with resulting preterm birth
Symptoms of Preterm Labor
Variations in Prenatal Care

 Cultural influences
Emotional response
Clothing
Physical activity and rest
Sexual activity
Diet
Variations in Prenatal Care

 Age
 Adolescents
Much less likely than older women to receive
adequate prenatal care
 Women older than 35 years
Multiparous women
Nulliparous women
Variations in Prenatal Care

 Multifetal pregnancy
 Twin pregnancies often end in prematurity
 Rupture of membranes before term common
 Congenitalmalformations twice as common in
monozygotic twins as in singletons
 No increase in incidence of congenital
anomalies in dizygotic twins
Variations in Prenatal Care

 Multifetal pregnancy (cont’d)

 Multifetal pregnancy probability increased by:
History of dizygous twins in female lineage
Use of fertility drugs
Rapid uterine growth for weeks of gestation
Hydramnios

Palpation of more small or large parts than expected

 Variations in Prenatal Care
 Multifetal pregnancy (cont’d)
 Multifetal pregnancy probability increased by:
Asynchronous fetal heartbeats or more than
one fetal electrocardiographic tracing
Ultrasonographic evidence of more than one
fetus
Variations in Prenatal Care

 Multifetal pregnancy (cont’d)

 Prenatal care given women with multifetal pregnancies
includes changes in:
Pattern of care
Amount of weight gained
Nutritional intake observed
 Uterine distention can cause severe backache
Variations in Prenatal Care

 Multifetal pregnancy (cont’d)

 Multiple newborns may place strain on:
Finances

Space

Workload

Woman’s and family’s ability to cope

 Lifestyle changes may be necessary
 Parents need help in planning for care
Childbirth and Perinatal Education

 Perinatal education goals

 Establish lifestyle behaviors for optimal health
 Prepare psychologically for pregnancy and the
responsibilities that come with parenthood
 Identify, minimize, and treat risk factors
 Screen health hazards in workplace and home
 Get genetic counseling for inherited diseases
 Compare perinatal care options available
Perinatal Education

 Goal is to help individuals and family members to

make informed and safe decisions about
pregnancy, birth, infant care, and early
parenthood
 Classes for expectant parents
 Education programs consist of a menu of class
series and activities from preconception
through the early months of parenting.
Perinatal Care Choices

 Physicians
 Midwives
 Certified nurse-midwives (CNMs)
 Direct entry midwives or certified midwives (CMs)
 Traditional or lay midwives
 Doulas
 Birth plans
Birth Setting Choices

 Hospital
 Labor, delivery, recovery rooms (LDRs)
 Labor,delivery, recovery, postpartum rooms
(LDRPs)
 Birth centers
 Home birth
 Remains a controversial topic in American health
care
Key Points

 The prenatal period is a preparatory one both

physically, in terms of fetal growth and parental
adaptations, and psychologically, in terms of
anticipation of parenthood.
 Pregnancy affects parent-child, sibling-child, and
grandparent-child relationships.
 Discomforts and changes of pregnancy can cause
anxiety for the woman and her family and require
sensitive attention and a plan for teaching self-
management measures.
Key Points (Cont.)

 Education about safety during activity and exercise is

essential, given maternal anatomic and physiologic
responses to pregnancy.
 Important components of the initial prenatal visit include
detailed and carefully documented findings from the
interview, a comprehensive physical examination, and
selected laboratory tests.
 Follow-up visits are shorter than the initial visit and are
important for monitoring the health of the mother and
fetus and providing anticipatory guidance as needed.
Key Points (Cont.)

 Even in normal pregnancy the nurse must remain

alert to hazards such as supine hypotension, signs
and symptoms of potential complications, and signs
of family maladaptations.
 Blood pressure is evaluated on the basis of absolute
values and length of gestation and is interpreted in
light of modifying factors.
 Each pregnant woman needs to know how to
recognize and report signs of potential
complications such as preterm labor.
Key Points (Cont.)

 There is an increased incidence of physical, mental,

and verbal abuse during pregnancy.
 Culture, age, parity, and multifetal pregnancy can
have a significant effect on the course and outcome
of the pregnancy.
 Nurses must ask pregnant women and their families
about preferences, practices, and customs related
to childbearing to provide culturally sensitive care.
Key Points (Cont.)

 Childbirth education teaches tuning in to the

body’s inner wisdom and coping strategies that
enhance women’s ability to cope effectively with
labor and birth.
 Perinatal education strives to promote healthier
pregnancies and family lifestyles.
 Nurses can help pregnant women and their
families to make informed decisions about care
providers, birth settings, and labor support.
Question

1. With regard to follow-up visits and the physical examination for women receiving
prenatal care, nurses should be aware that:
a. The interview portions become more intensive as the
visits become more frequent over the course of the
pregnancy.
b. Monthly visits are scheduled for the first trimester, every
2 weeks for the second trimester, and weekly for the
third trimester.
c. During the abdominal examination, the nurse should be
alert for supine hypotension.
d. For pregnant women, a systolic blood pressure (BP) of
130 mm Hg and a diastolic BP of 80 mm Hg is sufficient
to be considered hypertensive