1. Nursing Care of the Family During Pregnancy
Chapter 14

2. 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.

3. 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.

4. Nursing Care during Pregnancy
Prenatal period
Period of 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

5. Nursing Care during 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

6. 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)

7. Diagnosis of Pregnancy
Signs and symptoms (cont’d)
Probable indicators
Uterine enlargement
Braxton Hicks contractions
Uterine souffle
Ballotement
Positive pregnancy test

8. 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)

9. 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

10. 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

12. 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

13. Adaptation to Pregnancy (Cont.)
Adaptation to parenthood for the nonpregnant partner
Sibling adaptation
Depends on age and dependency needs
Grandparent adaptation

14. 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

15. 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

16. 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
Prenatal care is sought routinely by women of middle or high socioeconomic status

17. 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

18. 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

19. 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

20. 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

21. Schedule of Prenatal Visits
1 X a month until 28th week
Every 2 weeks until 36th week
Weekly from 37th until delivery

22. 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

23. 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

25. Care Management Assessment (cont’d) Follow-up visits Interview
Physical examination
Fetal assessment
Fundal height
Gestational age
Health status

26. Detecting Fetal Heartbeat

27. 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

28. 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

29. 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 

30. 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

31. Care Management Nutrition Personal hygiene
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

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

33. Self Care Education Posture and body mechanics Rest and relaxation
Employment
Clothing
Travel
Medications and herbal preparations
Immunizations

34. 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

35. Rest, recreation and Sleep
Napping for 30 min in am and pm. Beneficial

36. 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

37. Bowel Habits Prevent Constipation by Drinking large amounts of fluid
Diet containing fresh fruit raw veg, and whole grain breads and bran
Citracel or Metamucil add bulk to stool
Stool softeners
MOM
dioctyl sodium sulfosuccinate

38. Hemorrhoids Prevent constipation
If protruding gently push back into rectum
Knee chest position
Icebag or cold compresses with witch hazel or Epsom salts
Sitz bathes
Kegel Exercise

39. 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

41. 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

42. 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

43. 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

44. Symptoms of Preterm Labor

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

46. 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

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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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.

55. Perinatal Care Choices
Physicians
Midwives
Certified nurse-midwives (CNMs)
Direct entry midwives or certified midwives (CMs)
Traditional or lay midwives
Doulas
Birth plans

56. 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

57. 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.

58. 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.

59. 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.

60. 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.

61. 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.

62. Question
With regard to follow-up visits and the physical examination for women receiving prenatal care, nurses should be aware that:
The interview portions become more intensive as the visits become more frequent over the course of the pregnancy.
Monthly visits are scheduled for the first trimester, every 2 weeks for the second trimester, and weekly for the third trimester.
During the abdominal examination, the nurse should be alert for supine hypotension.
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