CHAPTER 8:

NURSING CARE OF THE

FAMILY DURING
PREGNANCY
LEA NIZZA SANTILLAN
ARIANE JABOLI
 Prenatal period provides a unique opportunity for nurses and other
members of the interprofessional health care team to influence pregnancy
outcome and family health.
 Prenatal care is designed to monitor the growth and development of the
fetus and to identify abnormalities that will interfere with the course of
normal labor.
 Prenatal provides education and support for maternal self-care and
parenting and includes the spouse or partner or significant
 1st trimester: 1-13weeks, 2nd trimester: 14-26weeks, 3rd trimester: 27 to
40weeks.
DIAGNOSIS OF PREGNANCY

 SIGNS AND SYMPTOMS

 Classified as Presumptive, Probable or Positive

 ESTIMATING DATE OF BIRTH

 Estimated Date of Delivery (EDD) aka Estimated Date of Birth (EDB) is important
for planning prenatal care, scheduling specific prenatal screening tests,
assessing fetal growth, and making critical decisions for managing pregnancy
complications.
 Most accurate assessment of EDB is based on ultrasound measurement of the
embryo or fetus during the first trimester of pregnancy.
 NAEGEL’S RULE: 1st day of LMP -3 calendar months +7 days
ADAPTATION TO PREGNANCY

FAMILY,
traditional or non-traditional,
is the best source of information about their
beliefs,
needs and concerns.
1. 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 from being self-contained and independent to
being committed to a lifelong concern for another human being.
1.1 ACCEPTING PREGNANCY

 This is the first step in adapting to the maternal role.

 Eventual acceptance of pregnancy parallels growing acceptance of
reality of a child. However, nonacceptance of the pregnancy does not
equate with rejection of the child, because a woman can dislike being
pregnant but feel love for the child to be born.
 Emotional Lability – rapid and unpredictable changes in mood due to
profound hormonal changes.
 Ambivalence – having conflicting feelings simultaneously, which is
considered a normal response for people preparing for a new role.
 Intense feeling of ambivalence that persist through the 3rd trimester can indicate
an unresolved conflict with the motherhood role.
1.2
IDENTIFYING MOTHER ROLE

 Begins when she is mothered as a child.

 Practice roles, such as playing dolls, babysitting and taking care of siblings
can increase her understanding of what being a mother involves.
1.3
REORDERING PERSONAL RELATIONSHIPS
 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 prenatal visits.
 Although the woman’s relationship with her mother is significant in
considering her adaptation to pregnancy, the MOST important person to
the pregnant woman is usually the Father of her child.
 With same-sex couples, the most important person is the Partner.
 Women expresses two major needs within the relationship during
pregnancy: feeling loved and having the child accepted by the partner.
1.4 ESTABLISHING A RELATIONSHIP WITH
THE FETUS
 The mother-child relationship progresses through pregnancy as a
developmental process that unfolds in 3 phases:
 Phase 1: the woman accepts the biologic fact of pregnancy.
“I am pregnant.”
 Phase 2: the woman accepts the growing fetus as distinct from herself.
“I am going to have a baby.”
 Phase 3: the woman prepares realistically for the birth and parenting of the child.
“I am going to be a mother.”
1.5 PREPARING FOR BIRTH

 Many women actively prepare for birth by reading books and information
on various websites.
 Anxiety can arise from concern about a safe passage for herself and her
child during the birth process (Mercer, 1995; Rubin, 1975, 1984)
 Many women fear the pain of labor and birth because they do not
understand anatomy and the birth process.
 Most women become impatient for labor to begin, whether the birth is
anticipated with joy, dread, or a mixture of both.
 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 birth.
2. PATERNAL ADAPTATION

 The father’s beliefs and feeling about the ideal mother and father and his
cultural expectations of appropriate behavior during pregnancy affect his
response to his partner’s need for him.
 Some men view pregnancy as proof of their masculinity and their dominant
role.
 To others, pregnancy has no meaning in terms of responsibility to either
mother or child.
 Preganancy is a time of preparation for the parental role with intense
learning.
2.1 ACCEPTING PREGNANCY

 Couvade: he behaved in specific ways and respected taboos associuated

with pregnancy and giving birth so his new status was nrecognized and
endorsed.
 Couvade Syndrome: some men experience pregnancy-like symptoms,
such as nausea, weight gain, and other physical symptoms.
 Phases of developmental pattern:
 The announcement phase
 Lasts from few hours to a few weeks.
 The developmental task is to accept the biologic fact of pregnancy.
 The moratorium phase
 when he adjusts to the reality of pregnancy.
 The developmental task is to accept the pregnancy.
 The focusing phase
 Begins in the last trimester
 Characterized by father’s active involvement in both pregnancy and relationship to the
child.
 The developmental task is to negotiate with his partner the role he is to play in labor and
to prepare for parenthood.
2.2 IDENTIFYING
WITH THE FATHER ROLE

Some men are highly motivated to nurture and love a child.

They are excited and pleased about the anticipated role of a father.
Others are more detached or even hostile to the idea of parenthood.
2.3 REORDERING PERSONAL
RELATIONSHIPS

 The partner’s main role is in pregnancy is to nurture and respond to the

pregnant woman’s feelings of vulnerability.
 The partner’s support indicates involvement in the pregnancy and
preparation for attachment to the child.
2.4 ESTABLISHING A RELATIONSHIOP
WITH THE FETUS
 Fathers can be as competent as mothers in nurturing their infants.

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

 How do you expect the baby to look and act?

 How do you envision life as father?
 How will you be involved in helping to care for the baby?
 How will having a baby affect your relationship with your partner?
2.5 PREPARING FOR BIRTH

 Major concerns for the man are getting the woman to a health care facility
in time for the birth and not appearing ignorant.
 They also have fears concerning safe passage of his child and partner and
the possible death or complications of his partner and child.
 It is important to verbalize these fears.
 Mothers often sense the tensions and apprehensions of the unprepared,
unsupported father, and it can increase their fears
3. ADAPTATION TO PARENTHOOD FOR
THE NONPREGNANT PARTNER
 The same fears, questions and concerns can affect birth partners who are
not biologic fathers or who are the nonpregnant partner in a same-sex
couple.
 Much attentions is paid to the needs of the pregnant woman, but
nonpregnant partner’s needs receive less attention.
 Partners need to be kept informed, supported and included in all activities
in which the mother desires their participation.
4. SIBLING ADAPTATION

 The older chils oftern experiences a sense of loss or feels jealous at being
“replaced” by the new sibling.
 1yo child: largely unaware of the process.
 2yo: notices changes in mother’s appearance.
 3yo or 4yo: children like to be told the story of their own beginning &
accept a comparison of their own development with that of the present
pregnancy.
 School-age: They may want to know in more detail.
 Early & Middle Adolescents: preoccupied of their own sexual identity.
 Late adolescents: do not appear to be unduly disturbed.
5. GRANDPARENT ADAPTATION

 It reawakens the 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.
 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.
CARE MANAGEMENT

PRENATAL CARE
 optimal care is provided by an interprofessional team that includes the
obstetric care provide, nurses and other health care professionals and
support groups.
 The goal is to promote the health and well-being of the pregnant woman,
her fetus, the newborn, and the family.
 In holistic care, nurses provide information and guidance about the
physical changes and the psychosocial impact of pregnancy on the
woman and members of the family.
 The goals of prenatal nursing care are to foster a safe birth for the mother
and infant and to promote satisfaction of the mother and family with the
pregnancy and birth experience.
CARE MANAGEMENT

PRENATAL CARE
 Women’s reasons to delaying prenatal care include cost, lack of insurance,
child care, transportation barriers, or inability to take time off from work.
 Lack of culturally sensitive care providers, discrimination based on sexual
orientation, and barriers to communication resulting from differences in
language also interfere with access to care.
 Problems with preterm birth, low birth weight (LBW: less than 2500g) and
infant mortality are associated with lack of adequate prenatal care.
 Initial visit: first trimester monthly until week 28 of pregnancy, every 2weeks
until week 36 & every week until birth.
 Prenatal care is ideally a multidisciplinary activity in which nurses work
collaboratively with health care providers.
INITIAL VISIT
Prenatal Interview

 During this interview, the nurse has the opportunity to gain the woman’s
trust.
 The initial evaluation includes comprehensive health history emphasizing
the current pregnancy, previous pregnancies, the family, the psychosocial
profile, a physical assessment, diagnostic testing, and an overall risk
assessment.
INITIAL VISIT
Prenatal Interview
 Reason for Seeking Care
 Reassurance about a particular reason
 Current Pregnancy
 Signs of pregnancy, review of symptoms
 Obstetric and Gynecologic History
 Woman’s age at menarche, menstrual history & contraceptive history
 Any infertility or reproductive system conditions
 History of STDs, sexualn history, detailed history of all pregnancies including the
present pregnancy, and their outcomes.
 Date of last Papanicolau (Pap) test and result are noted.
 Date of LMP is obtained to calculate the EDB.
INITIAL VISIT
Prenatal Interview
 Health History
 Includes all physical or surgical procedures that can affect the pregnancy or
that can be affected by the pregnancy.
 Women who have chronic or handicapping conditions.
 Nutritional History
 Nutritional status has direct effect on the growth and development of the fetus.
 Body Mass Index (BMI) should be calculated
 Maternal weight gain and fetal growth should be closely monitored.
INITIAL VISIT
Prenatal Interview
 History of Drug and Herbal Preparation
 Includes past and present use of drugs.
 Many substances cross the placenta and can therefore pose a risk to the
developing fetus.
 Allergies to medication & type of reaction should also be obtained & recorded
 Immunization record should be reviewed for vaccinations against rubella
(German measles, varicella (chickenpox), seasonal influenza, hepatitis B &
pertussis (whooping cough).
 Family History
 Can help identify familial or genetic disorders or conditions that can affect the
health status of the woman or the fetus.
INITIAL VISIT
Prenatal Interview
 Social, Experiential and Occupational History
 During interviews throughout the pregnancy, nurses should remain alert to the
appearance of potential parenting problems, such as depression, lack of family
support, and inadequate living conditions.
 Nurses 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.
 Nurse should determine the woman’s knowledge in various areas: pregnancy,
maternal changes, fetal growth, self-care, and care of the newborn, including
feeding.
 Occupation:
 Standing long hours: Orthostatic Hypotension
 Long hours of sitting: Carpal tunnel syndrome or Ciuclatory stasis in the legs.
INITIAL VISIT
Prenatal Interview
 Mental health screening

 Perinatal depression is the most common complication of pregnancy and if

untreated, can have serious adverse effects on the mother, her newborn and
her family.
 Screening at least once during perinatal period
 Risk factors for depression or anxiety during pregnancy include lack of support fro
partner, inadequate social support, history of intimate partner violence, personal
history of mental illness, unintended pregnancy complications of loss, and
stressful events.
INITIAL VISIT
Prenatal Interview
 Intimate Partner Violence
 AKA battering, domestic abuse or domestic violence.
 Risk factors: younger age, unintended pregnancy, lower income & lower level of
education.
 Physical assault especially to the abdomen, and sexual trauma increase the risk
for spontaneous abortion (miscarriage), antepartum hemorrhage, abruptio
placentae, preterm birth, low birth weight, maternal death & neonatal death.
 Abuse Assessment Screen – a simple and widely used tool of screening for IPV.
 if woman discloses IPV:
 First step: assess for immediate danger and to take action to protect the woman & her
children
 Next: help the woman to formulate a safety plan.
INITIAL VISIT
Prenatal Interview

 Review of Systems
 The woman is asked to identify and describe preexisting or concurrent problems
in any of the body systems; and her mental status is assessed.
PHYSICAL EXAMINATION

 Initilal physical examination provides the baseline for assessing subsequent

changes.
 Begins with assessment of vital signs and height a d weight (for calculation
of BMI)
 The nurse must remain alert to the woman’s cues that give direction to the
remainder of thw assessment and that indicate a potential threatening
condition:
 Supine Hypotension – low BP that occurs while woman is lying on her back,
causing feeling of faintness
LABORATORY TESTS

 Women should receive information information about the various tests and
the purpose for each test and be provided an opportunity to opt-out of
testing.
 All pregnant women should receive HIV risk reduction counselling.
LABORATORY TESTS
LABORATORY TEST
Hemoglobin, Hematocrit, WBC,
differential
Hemoglobin Electrophoresis
Blood type, Rh, & irregular antibody
Rubella Titer
Tuberculin Test; chest x-ray after 20
weeks if gestation in women with
reactive tuberlin tests
Urinalysis, including microscopic
examination ofn urinary sediment; pH,
specific gravity, color, glucose,
albumin, protein, RBCs, WBCs, casts,
acetone; hCG
PURPOSE
Detects anemia, infection
Identifies women with
hemoglobinopathies
Fetuses are at risk for developing
erythroblastosis fetalis of
hyperbilirubirubinemia
Immunity to rubella
Screens for exposure to tuberculosis
Identifies women with glycosuria, renal
disease, hypertensive disease of
pregnancy; infection, occult
hematuria; hCG for confirmation of
pregnancy
LABORATORY TESTS
Laboratory Test
Urine culture
Renal function tests: BUN, creatinine,
electrolytes, creatinine clearance,
total protein excretion
Pap test
Cervical cultures for Neisseria
gonorrhoeae, Chlamydia
Vaginal/ anal culture
Purpose
Identifies women with asymptomatic
bacteriuria
Evaluates level of possible renal
compromise in women with a history
of diabetes, hypertension, or renal
disease
Screens for cervical intraepithelial
neoplasia; if liquid-based test is used ,
may also screen for HPV
Screens for asymptomatic infection at
first visit
GBS test done at 35-37 weeks for
infection
LABORATORY TESTS
Laboratory Test
RPR, VDRL, FTA-ABS
HIV antibody, hepatitis B surface
antigen, toxoplasmosis
1hour glucose tolerance
3-hour glucose tolerance
Cardiac evaluation: ECG, chest x-ray,
and echocardiogram
Purpose
Identifies women with untreated
syphilis, done at first visit
Screens for specific infections
Screens for gestational diabetes;
done at initial visit for women with risk
factors; done at 24-28 weeks for
pregnant women at risk whose initial
screen was negative and to others
who were not previously tested
Test for gestational diabetes in women
with elevated reading for diagnosis
Evaluates cardiac function in women
with and history of hypertension or
FOLLOW-UP VISITS

 Interview
 Physical Examination
 BP, Weight, BMI, examination of the abdomen
 Fetal Assessment
 Quickening usually occurs between 16 and 20 weeks of gestation
 Ultrasonography (sonogram) is used to determine the estimated date of birth &
to establish the duration of pregnancy.
 Fetal Heart Tones
 Assessed routinely.
 Heartbeat can be heard with a Doppler device.
 Pinard horn – fetoscope commonly used by midwives & in much Europe.
SIGNS OF POTENTIAL COMPLICATIONS:
1st, 2nd & 3rd trimesters
Signs and Symptoms
Severe vomiting
Chills, fever, burning on urination,
diarrhea
Abdominal cramping, vaginal
bleeding
** persistent severe vomiting
Sudden discharge of fluid from vagina Preterm premature rupture of
before 37 weeks
Vaginal bleeding, severe abdominal
pain
Chills, fever, burning on urination,
Possible causes
Hyperemesis gravidarum
Infection
Miscarriage, ectopic pregnancy
Hyperemesis gravidarum,
hypertension, preeclampsia
membranes (PPROM)
Miscarriage, placenta previa,
abruptio placentae
Infection
SIGNS OF POTENTIAL COMPLICATIONS:
1st, 2nd & 3rd trimesters
Signs and Symptoms Possible causes
Severe backache or flank pain Kidney infection or stones; preterm
labor
Change in fetal movements: absence Fetal jeopardy or intrauterine fetal
of fetal movements after quickening, death
any unusual change I pattern or
amount
Uterine contractions, pelvic pressure, Preterm labor
cramping before 37 weeks
Visual disturbances: blurring, double Hypertensive conditions,
vision, or spots preeclampsia
Swelling of face or fingers and over Hypertensive conditions,
sacrum preeclampsia
Headaches: severe, frequent, or Hypertensive conditions,
continuous preeclampsia
SIGNS OF POTENTIAL COMPLICATIONS:
1st, 2nd & 3rd trimesters
Signs and Symptoms
Muscular irritability or seizures
Epigastric or abdominal pain
(perceived as heartburn or severe
stomachache)
Glycosuria, positive glucose tolerance
test reaction
Possible Causes
Hypertensive conditions,
preeclampsia
Hypertensive conditions,
preeclampsia; abruptio placentae
Gestational diabetes mellitus
FOLLOW-UP VISITS

 Health Status
 Includes consideration of fetal movement
 Absence of fetal movement is correlated with fetal death
 Fundal Height
 The measurement of the height of the uterus above the symphysis pubis
 One indicator of fetal growth.
 Measurement also provides a gross estimate of the duration of pregnancy.
 FH measurement can iad in identifying risk factors.
 Stable/ Decreased FH – intrauterine growth restriction (IUGR)
 Excessive increase – presence of multifetal gestation or polyhydramnios.
LABORATORY TESTS

 Clean-catch urine specimen

 Sequential integrated screening (SIS) – for women who begin prenatal care
before 14 weeks of gestation; 2 blood tests & 1 ultrasound. This can identify:
Down syndrome, trisomy 18, neural tube defects (anencephaly, spina
bifida), abdominal wall defects (gastroschisis and omphalocele) and Smith-
Lemli-Opitz syndrome.
 Blood Glucose screening
 Group B Streptococcus (GBS) testing
NURSING INTERVENTIONS
Education for Self-Management

 Expected Maternal and Fetal Changes

 Educational literature that describes maternal and fetal changes can be used to
explain changes as they occur.
 Nutrition
 Education for pregnant women includes recommendations about daily intake of
nutrients, calories, vitamins, & minerals.
 Food high in Iron, the importance of taking prenatal vitamins and
recommendations to avoid alcohol and limit caffeine intake.
 Personal Hygiene
 During pregnancy, sebaceous glands are highly active because of hormonal
influence and women often perspire freely.
 Baths and warm showers can be therapeutic.
NURSING INTERVENTIONS
Education for Self-Management
 Prevention of Urinary Tract Infection
 These are common during pregnancy.
 Pose a risk to the mother and fetus, and thus, prevention or early treatment is
essential. Oral antibiotics are commonly prescribed.
 Some women do not consume enough fluid.
 Kegel Exercises
 Deliberate contraction and relaxation of the pubococygeus muscle
 Strengthen the muscles around the reproductive organs and improve muscle
tone.
NURSING INTERVENTIONS
Education for Self-Management
 Preparation for Breastfeeding
 A woman’s decision to method of infant feeding is made before pregnancy.
 The woman and her partner are urged to decide which method of feeding is
suited for them; however, the benefits of breastfeeding should be emphasized.
 Soap, ointments, alcohol and tinctures should not be applied because they
remove protective oils that keep the nipples supple.
 Oral Health
 There is an increased incidence of gingivitis and peridontitis (infection of the
gums that can cause damage to soft tissues and bones)
 Antibacterial therapy should be considered for prevention of sepsis, especially in
pregnant women who have rheumatic heart disease or nephritis.
NURSING INTERVENTIONS
Education for Self-Management
 Physical Activity
 Physical activity during pregnancy has minimal risks and promotes feeling of well-
being in the pregnant woman.
 It improves physical fitness, enhances psychologic well-being, improves
circulation, promotes relaxation and rest, and counteracts boredom.
 Posture and Body Mechanics
 Poor posture and body mechanics contribute to the discomfort and potential for
injury.
 Rest and Relaxation
 The side-lying position is recommended because it promotes uterine perfusion
and fetoplacental oxygenation by elimination pressure on the ascending vena
cava & descending aorta which can lead to supine hypotension.
NURSING INTERVENTIONS
Education for Self-Management
The ability to relax consciously and intentionally is beneficial for the following
reasons:
 To relieve the normal discomforts reated top pregnancy
 To reduce stress and therefore diminish pain perception during the
childbearing cycle
 To heighten self-awareness and trust in one’s own ability to control
responses and functions
 To help cope with stress in everyday life situations.
Clinical Reason Case Study
Exercise in Pregnancy
Lourdes is 16 weeks pregnant with her second child. She wants to avoid
gaining extra weight during this pregnancy and would like to continue her
execise habits: walking and Zumba classes. What guidance can you give to
Lourdes?
1. Evidence – is the evidence sufficient to make a recommendation for a
against exercising during pregnancy?
2. Assumptions – describe the underlying assumptions for each of the
following issues:
1. Physiologic changes in pregnancy that affect balance, movement, respiration,
and cardiac function
2. Maternal physiologic response during exercise
3. Benefits of exercise
Clinical Reason Case Study
Exercise in Pregnancy
3. What implications and priorities for nursing care can be drawn at this time?
4. Does the evidence objectively support your conclusion?
5. Describe the roles/ responsibilities of members of the interprofessional health
care team who may be involved in caring for Lourdes.