Chapter 11

1. Chapter 11 Nursing Care During Pregnancy Debbie Hogan RN

2. 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

3. Nursing Care During Pregnancy—cont’d • 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

5. 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)

6. Diagnosis of Pregnancy—cont’d • Signs and symptoms • Probable indicators • Uterine enlargement • Braxton Hicks contractions • Uterine souffle • Ballottement • Positive pregnancy test

7. Diagnosis of Pregnancy—cont’d • Signs and symptoms • Positive indicators • Presence of fetal heartbeat distinct from mother’s • Fetal movement felt by someone other than mother • Visualization (e.g., ultrasound examination)

8. Diagnosis of Pregnancy—cont’d • Estimated date of birth (EDB) • Formulas for calculating EDB but none infallible • Nägele’s rule • Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days plus 1 year • Alternatively add 7 days to LMP and count forward 9 months • Most women give birth from 7 days before to 7 days after EDB

9. Adaptation to Pregnancy • Maternal adaptation • Accepting pregnancy • Identifying with mother role • Reordering personal relationships • Establishing relationship with fetus • Emotional attachment • Preparing for childbirth

10. Adaptation to Pregnancy—cont’d • Paternal adaptation • Accepting pregnancy • Identifying with father role • Reordering personal relationships • Establishing relationship with fetus • Emotional attachment • Preparing for childbirth • Sibling adaptation • Grandparent adaptation

11. Nursing 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

12. Nursing Care Management—cont’d • 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 low birth rate and infant mortality associated with inadequate prenatal care

13. Nursing Care Management—cont’d • Barriers to obtaining prenatal care include: • Inadequate number of providers • Unpleasant facilities or procedures • Inconvenient clinic hours • Distance to facilities • Lack of transportation • Fragmentation of services • Inadequate finances • Personal and cultural attitudes

14. Nursing Care Management—cont’d • 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

15. Nursing Care Management—cont’d • Initial visit: interview • Reason for seeking care • Current pregnancy • Obstetric and gynecologic history • Medical history • Nutrition history • History of drug use and herbal preparations

16. Nursing Care Management—cont’d • Initial visit: interview • Family history • Social, experiential, and occupational history • History of physical abuse • Review of systems • Initial visit: physical examination • Initial visit: laboratory tests

17. Nursing Care Management—cont’d • Follow-up visits • Interview • Physical examination • Fetal assessment • Fundal height • Gestational age • Health status

18. Nursing Care Management—cont’d • Follow-up visits • Fetal assessment • Laboratory tests • Multiple-marker or triple-screen blood test • Other blood tests (RPR/VDRL, CBC, anti-Rh) • Other tests • Ultrasonography • Amniocentesis

19. Nursing Care Management—cont’d • Nursing care • Care paths • Education for self-management • Nutrition • Personal hygiene • Prevention of urinary tract infections • Kegel exercises • Preparation for breastfeeding newborn • Dental health

20. Nursing Care Management—cont’d • Nursing care • Care paths • Education for self-management • Physical activity • Posture and body mechanics • Rest and relaxation • Employment • Clothing • Travel

21. Nursing Care Management—cont’d • Nursing care • Care paths • Education for self-management • Medications and herbal preparations • Immunizations • Alcohol, cigarettes, and other substances • Normal discomforts • Recognizing potential complications • Recognizing preterm labor

22. Variations in Prenatal Care • Cultural influences • Emotional response • Clothing • Physical activity and rest • Sexual activity • Nutrition

23. Variations in Prenatal Care—cont’d • Age differences • Adolescents • Much less likely than older women to receive adequate prenatal care • Women older than 35 years • Multiparous women • Nulliparous women

24. Variations in Prenatal Care—cont’d • 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

25. 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

26. Childbirth and Perinatal Education—cont’d • Options for care • Physicians • Nurse-midwives • Direct-entry midwives • Independent midwives • Doula • Birth Plans

27. Childbirth and Perinatal Education—cont’d • Birth setting choices • Labor, delivery, recovery, postpartum (birthing) rooms • Birth centers • Home birth • Factors increasing the safety of birth at home

28. Childbirth and Perinatal Education—cont’d • Components of perinatal education programs • Pain management • Relaxation • Imagery and visualization • Conscious breathing • Biofeedback • Massage and acupressure

29. Childbirth and Perinatal Education—cont’d • Preparation for cesarean birth • Almost 30% of births in the United States are surgical • Vary by provider and care setting • More common in women who choose epidurals • Vaginal birth after cesarean • Childbirth education outcomes

30. Key Points • Prenatal period is physically and psychologically preparatory • Psychosocial aspects may affect pregnancy, childbirth, and adjustment of the new family • Pregnant woman’s readiness to learn is high level and excellent time to help expand her self-care skills

31. Key Points—cont’d • Maternal physical and familial adaptations to pregnancy generate needs that nurse can anticipate and meet • Nurse must be alert to hazards such as supine hypotension, warning signs and symptoms, and signs of family maladaptation • Each pregnant woman needs to know how to recognize and report preterm labor

32. Key Points—cont’d • Parent-child, sibling-child, and grandparent-child relationships are affected by pregnancy • Cultural prescriptions and proscriptions influence responses to pregnancy and health care • Childbirth education helps parents make transition from role of expectant parents to role and responsibilities of parents