Chapter 4
Prenatal Care and Adaptations to Pregnancy
Preconceptual Care
Goal of prenatal care is no longer limited to the outcome of a healthy mother and
newborn
Expands to the prevention of adult disease in the developing fetus and newborn infant
Discuss pregnancy intention, access to care, use of MVI and folic acid, habits,
STI, illicit drug use, and mental health issues.
Obtain family, maternal, and chronic illness history.
Educate re: healthy weight, glycemic control, teratogenic medications.
NOTES:
Identifies risk factors that may be changed before conception
Reduce their negative impact on outcome of pregnancy
Ensure good nutritional state and immunizations
Ensure adequate intake of folic acid
To prevent neural tube defects in developing fetus
What factors should be addressed before conception to improve the pregnancy’s
outcome?
Phases of Pregnancy
Antepartum
Before birth (prenatal)
Intrapartum
During birth
Postpartum
After birth
NOTES:
Optimum obstetric care includes:
Preconceptual care
Includes preparation for the impact the newborn will have on family dynamics
and preparation and follow up of the preconception interview.
Prenatal care
Involves the monitoring, care and management of issues arising during
pregnancy.
Intrapartum care
Involves the continuous presence and support of the parents by a labor and
delivery nurse or doula during the birth process.
Postpartum care
Involves supporting the adjustment after birth including encouragement to
breast feed, skin-to-skin contact, and bonding while reducing separations and
interruptions. Early discharge to a busy household can interfere in mother–
infant bonding in early postpartum days. Follow-up care of mother and infant is
important.
Prenatal Care Providers
Obstetricians (physician, e.g., MD or DO)
Family practice physicians (MD or DO)
Certified nurse midwives (CNMs)
Nurse practitioners (NP)
The pregnant woman can select from a variety of prenatal health care providers to
manage her pregnancy.
The individualized needs of the woman, her family, and the unborn baby will
determine the best source of health care during the pregnancy.
Geographic location might determine the availability of the various health care
providers.
Discuss the availability of the different prenatal care providers in the local
community.
Major Goals of Prenatal Care
Ensure a safe birth for mother and child by promoting good health habits and reducing
risk factors.
Teach health habits that may be continued after pregnancy.
Educate in self-care for pregnancy.
Provide physical care.
Prepare parents for the responsibilities of parenthood.
Prenatal Visits
Ideally, prenatal care should begin before pregnancy to assist the woman in being in
optimal health before conception.
The gestation of the woman at the first prenatal care visit will vary.
Complete history and physical examination
Identify problems that may affect the woman and her developing fetus.
Ensure a healthy pregnancy and delivery of a healthy infant.
Components of Prenatal Health History
Obstetric
Menstrual
Contraceptive
Medical and surgical
Woman’s family
Partner’s family
Both woman’s and partner’s history to identify risk factors
Psychosocial
NOTES:
Obstetric history includes the number and outcomes of past pregnancies.
Menstrual history information focuses on the woman’s past cycles.
What questions will facilitate collection of data in this area?
The information related to contraceptive history focuses on the methods that have
been used. If these methods were taken before the pregnancy being confirmed, it will
be important to determine when.
Ensure the woman’s confidentiality during the interview process.
Physical Examination Objectives
Evaluate the woman’s general health.
Determine baseline weight and vital signs.
Evaluate nutritional status.
Identify current physical and social problems.
Determines the estimated date of delivery (EDD).
Recommended Schedule of Prenatal Visits—Uncomplicated Pregnancy
Conception to 28 weeks—every 4 weeks
29 to 36 weeks—every 2 to 3 weeks
37 weeks to birth—weekly
Certain laboratory and diagnostic tests are performed at various times throughout
pregnancy.
See Table 4-1.
NOTES:
Complications or concerns of the mother or health care provider necessitate a
modified schedule.
The activities of each visit will be determined by the gestation of the pregnancy and
the presence of health concerns or alterations.
Review the role of the nurse during the prenatal care visits.
What scenarios might require more frequent prenatal visits?
Routine Assessments at Each Prenatal Visit
Risk factors: review known and assess for new
Vital signs and weight: determine if gain is normal
Urinalysis: protein, glucose, and ketone levels
Blood glucose screening
Fundal height: fetal growth and amniotic fluid volume
Leopold maneuvers: assess presentation and position
Fetal heart rate
Nutrition intake
Any discomforts or problems since last visit
NOTES:
Each care initiative performed must be accompanied by an explanation.
The time spent during the physical examination and data collection provides an
optimal opportunity for assessing the educational needs of the pregnant woman.
What information should be provided to the patient concerning the urine collection
completed at each visit?
What questions will assist the nurse in obtaining the maximum amount of information
during the data collection?
What types of questions should be avoided?
Vaginal Discharge During Pregnancy
Bacterial vaginosis is most common
Caused by
Decrease in lactobacilli
Increase in bacteroids and other anaerobic microorganisms
May be milky-white discharge
No other clinical symptoms may be present.
Has been associated with preterm labor
The hormonal changes of pregnancy promote changes in the vaginal environment.
The hormonal changes could be associated with increased reports of discharge and
the presence of vaginal infection.
During the pregnancy, the woman must receive the needed educational tools
concerning the appropriate signs and symptoms to report.
Role of the Nurse During Prenatal Care
Collecting data from the pregnant woman
Identifying and reevaluating risk factors
Educating in self-care
Providing nutrition counseling
Promoting family adaptation to pregnancy.
NOTES:
Discuss Virtual Prenatal Care
“In-person” visits via HIPAA-protected electronic means
Requires consent forms
Use only with low-risk patients.
Terms Related to Pregnancy
Gravida
Nulligravida
Primigravida
Multigravida
Para
Primipara
Multipara
Nullipara
Abortion
Gestational age
Fertilization age
Age of viability
Determining the Estimated Date of Delivery
Average pregnancy is 40 weeks (280 days) after first day of LNMP, plus or minus 2
weeks
Nägele’s rule
Identify first day of LNMP.
Count backward 3 months.
Add 7 days.
Update year, if applicable.
NOTES:
Average pregnancy is 40 weeks (280 days) after first day of LNMP, plus or minus 2
weeks
Nägele’s rule
Identify first day of LNMP.
Count backward 3 months.
Add 7 days.
Update year, if applicable.
Trimesters
Pregnancy divided into three 13-week parts
Important to know what occurs during each trimester to both woman and fetus
Helps provide anticipatory guidance
Identify deviations from the expected pattern of development
NOTES:
What are potential topics of interest to pregnant women for each trimester?
Presumptive Signs of Pregnancy
Amenorrhea
Nausea
Breast tenderness
Deepening pigmentation
Urinary frequency
Fatigue and drowsiness
Quickening
NOTES:
Presumptive signs of pregnancy are those which are frequently associated with
pregnancy, but they could be attributed to many other phenomena as well.
Probable Signs of Pregnancy
Goodell sign
Chadwick sign
Hegar sign
McDonald sign
Abdominal enlargement
Braxton Hicks contractions
Ballottement or fetal outline
Abdominal striae
Positive pregnancy test result
NOTES:
Probable signs are associated with pregnancy and can be evidenced by an examiner.
Probable signs, like presumptive signs, can be associated with other situations.
Positive Signs of Pregnancy
Audible fetal heartbeat
Fetal movement felt by examiner
Ultrasound visualization of fetus
NOTES:
Positive signs can only be associated with the presence of pregnancy.
Normal Physiological Changes in Pregnancy
Role of microbiomes in pregnancy
Pregnancy causes many changes in body systems.
Endocrine
Reproductive
Respiratory
Cardiovascular
Gastrointestinal
Integumentary and skeletal
NOTES:
Microbiomes
Are the normal microbes in the individual’s own body.
Play a role in maintaining pregnancy, preparation for labor, and establishing a
microbiome that is passed on to the newborn.
These microbiomes contribute to development of the acidic vaginal changes
that occur during pregnancy that protect the woman from vaginal infections
and may play a role in preventing preterm births.
Research has shown that the microbes in the oral cavity of the mother is spread
by the blood to the placenta.
Explains the relationship between periodontal (dental) disease to preterm birth
due to the influence by placental functions
Aids in establishing the microbiome of the newb
Effects of Pregnancy on the Endocrine System
Dramatic increase in hormones affects all body systems
Essential to maintain pregnancy
Produced initially by the corpus luteum; later by the placenta
Most striking change is addition of placenta as a temporary endocrine organ
Primary role is to produce estrogen and progesterone to maintain pregnancy
Effects of Pregnancy on the Reproductive System
The body undergoes numerous changes during pregnancy.
These changes can be attributed to three factors: presence of estrogen,
presence of progesterone, and growth of the fetus.
Uterus
Becomes temporary abdominal organ
Capacity is 5000 mL (fetus, placenta, amniotic fluid)
Cervix
Changes in color and consistency, glands in cervical mucosa increase
Mucus plug formed to prevent ascent of organisms into uterus
Ovaries
Produce progesterone to maintain decidua (uterine lining) during first 6
to 7 weeks of gestation until placenta can take over task.
Vagina
Increased blood supply causes it to have a bluish color.
Vaginal secretions increase; pH more acidic.
Higher glycogen level, which promotes Candida albicans (yeast) growth
Breasts
High levels of estrogen and progesterone prepare breasts for lactation.
Tubercles of Montgomery secrete substance to lubricate nipples.
“Premilk” is expressed and is high in protein, fat-soluble vitamins, and
minerals.
Low in calories, fats, and sugar
Effects of Pregnancy on the Respiratory System
Oxygen consumption increases by 15%.
Diaphragm rises ~4 cm (1.6 inches)
Causes ribs to flare
Dyspnea can occur until fetus descends into pelvis.
Increased estrogen causes edema or swelling of mucous membranes of nose,
pharynx, mouth, and trachea.
Woman may complain of nasal stuffiness, epistaxis, and voice changes.
Effects of Pregnancy on the Cardiovascular System
Blood volume increases by ~45%
Increase provides for
Exchange of nutrients, oxygen, and waste products within the placenta
Needs of expanded maternal tissue
Reserve for blood loss at birth
Pulse rate increases by 10 to 15 beats/min.
The increase in the circulatory volume will peak between 32 and 34 weeks’
gestation.
There is a pulse rate increase during pregnancy.
During early pregnancy, the woman frequently experiences a reduction in blood
pressure. What factors can be attributed to this occurrence? Reduced vascular
resistance is responsible for the reduction in blood pressure.
Effects of Pregnancy on the Cardiovascular System
Orthostatic hypotension
Palpitations
Dilutional anemia (a.k.a. pseudoanemia)
Increased clotting factors in second and third trimesters
Increases risk of thrombophlebitis
During pregnancy, the woman will normally experience orthostatic
hypotension. What information should be provided to the patient concerning
this condition and its management?
Blood counts obtained in the first trimester often reflect a reduction in
hemoglobin. What factors could cause this occurrence?
Effects of Pregnancy on the Gastrointestinal System
Growing uterus displaces stomach and intestines
Increased salivary secretions
Oral mucosa may become tender and bleed more easily.
Appetite and thirst may increase.
Gastric acid secretions decrease.
Delayed gastric emptying and intestinal movement
Progesterone and estrogen relax muscle tone of gallbladder.
Leads to retained bile salts
Can cause pruritus during pregnancy
The effects of hormones of pregnancy on the gastrointestinal system can cause the
expectant mother a great deal of distress.
What types of manifestations experienced by the mother-to-be can be attributed to
these factors?
Excretes waste products of woman and fetus
Glomerular filtration rate of kidneys increases.
Glycosuria and proteinuria more common.
Water retention due to increased blood volume and dissolving nutrients
provided for fetus
Progesterone causes renal pelvis and ureters to lose tone, leads to urinary
stasis
Woman more susceptible to UTIs
99% of sodium is reabsorbed, leading to fluid retention
Effects of Pregnancy on the Urinary System
In the first and last trimester, the woman will experience frequent urination
related to pressure by the uterus on the bladder.
Additional changes in pregnancy respond to the needs of the growing fetus.
As cardiac output and the volume of circulating blood increase, the kidneys
also have an increased workload. The kidneys work to filter this increased
blood volume.
As the body strives to keep up with the volume, the woman might “spill”
glucose and protein into the urine.
Effects of Pregnancy on the Integumentary and Skeletal Systems
Striae
Spider nevi
Sweat and sebaceous glands become more active.
To dissipate heat from woman and fetus
Posture changes
Low backaches
Relaxation of pelvic joints
Waddling gait
Change in center of gravity
Balance may become an issue.
Striae (stretch marks) will fade after the pregnancy, but they will not totally
disappear.
Safety education is vital to the pregnant woman. As balance changes and
becomes affected, she might face difficulty with stairs and getting in and out
of the bathtub.
Supine Hypotension Syndrome.
Also called aortocaval compression or vena cava syndrome
Occurs if woman lies flat on her back
Allows heavy uterus to compress inferior vena cava
Reduces blood returned to her heart
Can lead to fetal hypoxia
Symptoms
Faintness
Lightheadedness
Dizziness
Agitation
Turning to one side, preferably the left side, relieves pressure on inferior vena cava.
NOTES: S
The risk of supine hypotension increases as pregnancy advances.
Nutrition Education
Read food labels.
Eat foods that are nutrient dense.
Protein versus sugary foods
NOTES:
RDA/RDI
No need to provide nutrients in excess of the upper limits of the recommended
dietary allowance (RDA)
The combination of supplements and food fortification must not exceed
present upper limits of safety, or adverse responses, such as toxicity, can occur
Recommended dietary intake (RDI) is an umbrella term that includes the RDA and
upper levels of intake
Nutrition for Pregnancy and Lactation
Women must be educated that they are not “eating for two.”
The intake must be evaluated for both caloric content and value to the growing fetus.
Weight Gain
Women of normal weight: 25 to 35 lb (11.4 to 15.9 kg)
Overweight women: 15 to 25 lb (6.8 to 11.3 kg)
Obese women: 11 to 20 lb (5 to 9.1 kg)
Multifetal pregnancy: twins—woman should gain 4 to 6 lb in first trimester and 1.5 lb
per week in second and third trimesters, for a total of 37 to 54 lb (16.5 to 24.5 kg)
NOTES:
The weight gain of a woman during pregnancy is closely tied to her prepregnant
status.
Women who are overweight are discouraged from dieting but are encouraged to
carefully monitor their diets.
Nutrition Requirements for Pregnant Women
First trimester:
Increase by 300 kcal/day
Weight gain up to 4.4 lb or 2 kg by end of trimester
Weight gain in second and third trimesters should be ~1 lb (0.44 kg)/week during rest
of pregnancy
Second trimester:
Increase by 40 to 340 kcal/day
Third trimester:
Increase by 110 to 450 kcal/day
NOTES:
Fluid intake should also increase by 8 to 10 oz of fluid per day, with water being the
primary source.
Nonwater sources of fluid are often sources of empty calories and warrant close
evaluation.
Low weight gain in pregnancy is associated with preterm labor.
Dietary intake in first trimester is 300 kcal above normal dietary intake and can be
increased as follows:
Protein—60 g/day
Calcium—1200 mg/day
Iron—30 mg/day
Folic acid—400 mcg (0.4 mg)/day
Special Nutrition Considerations
Pregnant adolescent
Sodium intake
Vegetarian
Pica
Lactose intolerance
Cultural preferences
Gestational diabetes mellitus
NOTES:
The pregnant adolescent is often faced with concerns about body image. Education is
needed to ensure she is aware of her nutritional responsibilities to the fetus. When
evaluating nutritional needs of the pregnant adolescent, gynecologic age must be
reviewed. Gynecologic age refers to the number of years between the onset of
menses and the date of conception.
Which pregnant adolescent will have the greatest nutritional needs? The shorter the
gynecologic age, the greater the nutritional needs.
Although sodium intake is not totally restricted, it should be carefully considered.
Identify high sodium “diet pitfalls.”
Discuss the unique concerns of vegans and methods that can be used to meet their
dietary needs.
Pica is a condition in which a woman eats nonfood substances. Potential sources of
intake include dirt, mud, starch, and chalk.
Nutritional Requirements During Lactation
Caloric intake during lactation should be about 500 calories more than the
nonpregnant woman’s RDA.
Protein intake should be 65 mg/day.
Calcium and iron intake are the same as during pregnancy.
Vitamin supplements are often continued during lactation.
Limit intake of caffeine and alcohol.
Drugs should only be taken on the advice of the health care provider.
Exercise During Pregnancy
Maternal cardiac status and fetoplacental reserve should be the basis for determining
exercise levels during all trimesters of pregnancy.
It is important to assess the exercise practices of the woman.
Goal of exercise during pregnancy should be maintenance of fitness, not improvement
of fitness or weight loss.
NOTES:
Women who have been exercising before pregnancy are the best candidates for
continuing in an approved exercise regimen.
Elevated temperature: can impact fetal circulation and cardiac function
Hypotension: can reduce blood flow to the fetus
Cardiac output: peripheral pooling decreases cardiac reserves for exercise
Hormones: changes in oxygen consumption and epinephrine, glucagon, cortisol,
prolactin, and endorphin levels
Other factors: moderate exercise has many benefits—more positive self-image, a
decrease in musculoskeletal discomfort during pregnancy, and a more rapid return
to prepregnant weight after delivery
The maternal temperature should not exceed 100.4°F.
What activities are restricted in pregnancy because of their potential to elevate the
mother’s body temperature? Hot tubs and saunas should be avoided.
Maternal exposure to elevated temperatures during the pregnancy has been
associated with miscarriage and neural tube defects.
Safety concerns mandate the type of exercise recommended for pregnancy. Certain
positions can cause supine hypotension syndrome or promote orthostatic hypotension.
What activities could be associated with these concerns?
During pregnancy, the length of continuous time spent exercising must be evaluated.
Prolonged exercise sends an elevated amount of blood to the skeletal muscles. What
impact does this have on the pregnancy? This increase will reduce the amount of
blood being circulated to the uterus.
Nursing Guidance for Exercise
Start with a warm-up and end with a cool-down
Do not exceed American College of Obstetricians and Gynecologists (ACOG)
recommendations for moderate exercise
Combined with balanced diet is beneficial
Eating 2 to 3 hours before exercise or immediately after is recommended.
Avoid marked changes in depth of water (e.g., scuba diving) and altitude.
Avoid becoming overheated; increase fluid intake.
Intensity of exercise should be modified based on the “talk test.”
Travel During Pregnancy
Air travel is generally safe.
Avoid sitting for extended periods of time.
Avoid locations that increase the risk of exposure to infectious diseases.
Bring a copy of obstetric records.
Obtain information about nearest health care facility.
Encourage hand hygiene and dietary precautions.
Provide the “recipe” for oral rehydration formula.
NOTES:
Travel is safest during the second trimester. What factors about this phase make it
the best one for travel?
What risks and discomforts are present in each trimester that will influence travel
plans and safety?
Common Discomforts in Pregnancy
Fatigue
Nasal stuffiness
Nausea
Heartburn
Constipation
Hemorrhoids
Vaginal discharge
Backache
Varicose veins
Leg cramps
Edema of the lower extremities
NOTES:
What nonpharmacologic methods can help manage these discomforts?
Psychosocial Adaptations to Pregnancy
Identifying and managing psychosocial problems is essential to the positive outcome
of pregnancy.
Nutritional needs and patterns relating to age, ethnicity, or financial constraints
should be discussed.
Impact of pregnancy and birth on various age groups
NOTES:
Pregnancy is a time of stress and change for both the pregnant woman and her family.
Close observation and early intervention are vital to the prevention of problems.
The needs and concerns of each pregnant woman will vary by demographic.
Impact on Mother
According to Reva Rubin, four maternal tasks the woman accomplishes during
pregnancy include:
Seeing safe passage for herself and her fetus
Securing acceptance of herself as a mother and for her fetus
Learning to give of self and to receive the care and concern of others
Committing herself to the child as she progresses through pregnancy
Development Stage of Fatherhood
Announcement when pregnancy is confirmed
Acceptance results in strengthening of family
Adjustment
Focus
Active plans for participation in labor, birth process
Impact on the Father
Cultural values influence the role of fathers because pregnancy and birth are viewed
exclusively as women’s work in some cultures
The nurse should not assume that a father is uninterested if he takes a less active role
in pregnancy and birth
Acceptance of the pregnancy results in strengthening of the family support system
and expansion of the social network
How and why has the role of the father changed over the past few decades?
Would you share personal stories about your own delivery experiences and the role of
the baby’s father or mother?
Impact on the Adolescent
The nurse must assess the girl’s developmental and educational level, as well as her
support system to best provide care for her.
Consider her developmental level and the priorities typical of her age.
Must cope with two of life’s most stress-laden transitions at the same time:
adolescence and parenthood
Adolescence is a time of change and adjustment. The pregnant adolescent faces
multiple hurdles as she transitions both developmentally and during pregnancy.
What potential concerns will most likely be experienced by the pregnant adolescent?
Impact on the Older Couple
Tend to adjust to the pregnancy because they are well-educated and have achieved
life experiences that enable them to better cope with realities of parenthood
An “older couple” includes a first-time mother who is 35 years of age or older.
Despite their positive adaptation related to the realities of parenthood, older couples
might have unique concerns. Frequently, older parents are faced with being
chronologically the oldest in their peer group. They might have additional health
concerns and needs. Their established peer group might have different goals and
activities that do not match well with a couple having a young baby.
Postponement of Pregnancy Until After Age 35
Effective birth control alternatives
Increasing career options for women
High cost of living
Development of fertilization techniques to enable later pregnancy
Impact on the Single Mother
May be an adolescent or a mature woman
May have unique emotional needs
Single women who plan pregnancies often prepare for the financial and lifestyle
changes
The single mother must be approached in a nonjudgmental manner by the nurse.
The role of the father with this baby must be considered in an individual manner, and
the nurse must never make assumptions.
Impact on the Single Father
May take an active interest in and financial responsibility for the child
May want to participate in plans for the child and take part in the care of the infant
after it is born
His participation is sometimes rejected by the woman.
How should the nurse approach the single father?
What rules will govern his involvement in the pregnancy and delivery?
Impact on the Grandparents
May eagerly anticipate the woman’s pregnancy
Some take a more active role in the care of the grandchild.
If grandparents and expectant couple have similar views of their roles, little conflict
is likely.
The nurse may be able to help the new parents to understand their own parents’
reactions and help them to negotiate solutions to conflicts that are satisfactory to
both generations.
Prenatal Education
Should progress according to the nursing process:
Assess the history and cultural needs.
Diagnose the knowledge deficit.
Plan the goals and priorities.
Outcomes identification clarifies expected outcomes.
Teach (intervene) the facts and rationales.
Evaluate knowledge gained and goals achieved.
The Effect of Pregnancy and Lactation on Medication Ingestion
Pregnancy affects the metabolism of medications.
May have subtherapeutic levels
Parenteral medications may be absorbed more rapidly due to increased cardiac
output.
Drugs can cross the placenta and can be passed through breast milk.
NOTES:
The changes in drug metabolism during pregnancy require each mother to report to
her health care provider all medications being taken. This accounting must include
both prescription and over-the-counter medications.
Discuss the impact of hormones on medication response.
FDA Pregnancy Risk Category for Drugs: ABCD-X
Category A: no risk demonstrated to the fetus in any trimester
Category B: no adverse effects in animals; no human studies available
Category C: Only prescribed after risks to the fetus are considered. Animal studies
have shown adverse reaction; no human studies available
Category D: definite fetal risks but may be given despite risks in life-threatening
situations
Category X: absolute fetal abnormalities. Not to be used any time during pregnancy
NOTES:
When administering medications to the pregnant patient, these categories must be
taken into consideration.
What actions should be taken by the nurse when adverse reactions in pregnancy are
associated with a prescribed medication?
New guidelines from the FDA are forthcoming. They will include narratives for most
medications and their effects on pregnancy and the developing fetus. The lactation
subsection includes men and women of reproductive age and the medications effect
on fertilization or pregnancy. Refer to current drug books for more information.
Immunizations and Pregnancy
Live virus vaccines (e.g., LAIV, MMR) are contraindicated during pregnancy.
Thimerosal should not be given during pregnancy because of risk of mercury
poisoning.
Avoid pregnancy for at least 1 month after receiving an MMR vaccine.
Select immunizations are allowable during pregnancy, such as influenza (injectable
form) and Tdap.
