Chapter 11.docx

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Published on 13 Jun 2012
School
McGill University
Department
Nursing
Course
NUR1 233
Chapter 11: Nursing Care During Pregnancy
First trimester: weeks 1-13
Second trimester: 14-26
Third trimester: 27-38/40
Diagnosis of Pregnancy
Signs and symptoms
o Presumptive:
Breast changes: 3-4 weeks
Amenorrhea: 4 weeks
Nausea, vomiting: 4-14 weeks
Urinary frequency: 6-12 weeks
Fatigue: 12 weeks
Quickening: 16-20 weeks
o Probable:
Goodell sign: 5 weeks
Chadwick sign: 6-8 weeks
Hegar sign: 6-12 weeks
Positive pregnancy test (serum): 4-12 weeks
Positive pregnancy test (urine): 6-12 weeks
Braxton Hicks contractions: 16 weeks
Ballottement: 16-28 weeks
o Positive:
Visualization of fetus by real-time ultrasound examination: 5-6 weeks
Fetal heart tones detected by ultrasound: 6 weeks
Visualization of fetus by radiographic study: 16 weeks
Fetal heart tones detected by Doppler ultrasound stethoscope: 8-17 weeks
Fetal heart tones detected by fetal stethoscope: 17-19 weeks
Fetal movements palpated: 19-22 weeks
Fetal movements visible: late pregnancy
Estimating date of birth
o Nagele’s rule: first day of LMP 3 months + 7 days + 1 year
o Another way: add 7 days to LMP and count forward 9 months
o Most women give birth during period extending from 7 days before to 7 days after EDB
Adaptation to pregnancy
Maternal adaptation
o First step in adapting to maternal role is accepting the idea of pregnancy and assimilating the pregnant state
into the woman’s way of life
o Degree of acceptance reflected in woman’s emotional responses
o Emotional lability: increased irritability, explosions of tears and anger, and feelings of great joy and
cheerfulness alternate with little or no provocation
o Ambilvalence: having conflicting feelings at the same time normal response
o Identifying with mother role: begins early in each woman’s life when she is being mothered as a child –
social group’s perception of what constitutes the feminine role can subsequently influence her toward
choosing between motherhood or a career, being single or married, being independent rather than
interdependent, or being able to manage multiple roles
o Reordering personal relationships
As family members learn their new roles, periods of tension and conflict may occur
Nursing interventions: promoting effective communication patterns between expectant mother and
own mother and between expectant mother and her partner
Most important person to the pregnant woman is usually the father of her child nurtured by partner,
has fewer emotional and physical symptoms, fewer labor and childbirth complications, and easier
postpartum adjustment
2 major needs from partner: feeling loved and values and having child accepted
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Sex: during first trimester the woman’s sexual desire may decrease especially if breast tenderness,
nausea, fatigue, or sleepiness
o Relationship with fetus
Emotional attachment: feelings of being tied by affection or love begin during prenatal period as
woman use fantasizing and daydreaming to prepare themselves for motherhood
Phase 1: woman accepts biological fact of pregnancy “I am pregnant”
Phase 2: accepts growing fetus as distinct from herself and as a person to nurture “I am going to
have a baby”
Phase 3: prepares realistically for the birth and parenting the child “I am going to be a mother” –
might speculate sex of child and personality traits based on fetal movements
o Preparing for childbirth
Anxiety: about safe passage for herself and child during birth process fear pain of childbirth
because do not understand anatomy and the birth process
End of pregnancy: breathing difficult, fetal movements vigorous enough to disturb sleep
backaches, frequency and urgency of urination, constipation, and varicose veins can become
troublesome
Strong desire to see the end of pregnancy, to be over and done with, makes women at this
stage ready to move on to childbirth
Paternal adaptation
o Accepting pregnancy: encouraged father participation in childbirth experience ex. coming to ultrasound
o Identifying with the father role: memories of fathering he received from own father, experiences he had with
child care, perceptions of the male and father roles within social group guide selection of tasks and
responsibilities he will assume
o Reordering personal relationships
Main role: nurture and respond to the pregnant woman’s feelings of vulnerability
Partner’s support indicates involvement and preparation for attachment to the child
Direct rivalry with fetus may be evident, especially during sexual activity
o Establishing relationship with fetus
Father-child attachment begins in pregnancy
Men prepare for fatherhood in many of the same ways that women prepare for motherhood
As birth day approaches, fathers have more questions about fetal and newborn behaviours
o Preparing for childbirth
Anticipation, anxiety, boredom, and restlessness
Last 2 months: expectant fathers experience a surge of creative energy at home and on the job
become dissatisfied with current living space
Major concerns: getting mother to a medical facility in time for the birth and no appearing ignorant
want to be able to recognize labor and determine when appropriate to leave for the hospital or call
physician
Sibling adaptation
o Older child: often experiences sense of loss or feels jealous at being “replaced’ by new baby
o Factors: age, parents’ attitudes, father’s role, length of separation from mother, hospital’s visitation policy
o Include children in pregnancy and being sympathetic to older children’s concerns about losing their places in
the family hierarchy
Nursing Management
Prenatal care sought routinely by women of middle or high socioeconomic status women living in poverty or who
lack health insurance may not be able to use public medical services or gain access to private care
Initial visit: 1st trimester monthly visits till week 28 then every 2 weeks until week 36 every week until birth
Therapeutic relationship: established during initial assessment interview
o Subjective: woman’s appraisal of her health status
o Objective: nurse’s observations – affect, posture, body language, skin color, and other signs
Reason for seeking care, current pregnancy, obstetric and gynecologic history (sexual history, age at menarche, etc),
medical history, nutritional history, history of use of drugs or herbal preparations, family history, physical abuse
history, review of systems (associated manifestations, aggravating or alleviating factors)
Social experiential, and occupational history
o Family’s ethnic and cultural background and socioeconomic status
o Feelings about pregnancy (wanted or unwanted)
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o Family support and external resources
o Coping mechanisms and possible stressors
Common stressors: child’s welfare, labor and birth process, behaviours of the newborn, the
relationship with the baby’s father and her family, changes in body image and physical symptoms
o Occupation (past and present)
Physical examination
o Determine woman’s need for basic information regarding reproductive anatomy and provide this info along
with a demonstration of the equipment that may be used during the examination
o Begin: vital signs BP, height, weight, BMI
o Bladder: empty before pelvic examination
o Urine speciment: obtained to test for protein, glucose, or leukocytes, or for other tests
o Heart and lung: evaluated and extremities examined
o Skin: changes in pigmentation, rashes and edema
o Hair: distribution, amount and quality findings reflect nutritional status, endocrine function, and hygiene
o Thyroid gland, breasts, and abdomen: height of fundus
o Pelvic examination: tone of pelvic musculature and woman’s knowledge of Kegel exercises assessed – size
of uterus (indication of duration of gestation)
Cervical and vaginal smears obtained for cytologic studies and diagnosis of infection
o Vaginal examination: one recommended during pregnancy another not done unless indicated for medical
reasons
Laboratory tests
o Specimens are collected at the initial visit so that any abnormal findings can be treated
o Sickle cells screen: recommended for women of African, Asian, or Middle Eastern descent
o Folate level: measured when indicated
o HIV testing: for all pregnancy women
o History of Cystic Fibrosis: check if carrier
o Urine: glucose (diabetes), protein (preeclampsia), and nitrites and leukocytes (UTI) tested by dipstick
o TB test: protein derivative tuberculin test may be administered to assess exposure to TB
o Finding of risk factors: repeat tests to make sure
Follow-Up visits
o 1st and 2nd trimesters: monthly visits
o Interview
At each follow-up visit woman asked to summarize relevant events that have occurred since previous
visit general emotional and psychological well-being, complaints or problems, and questions
Assess parents’ understanding of: warning signs that indicate emergencies such as bleeding and
abdominal pain, signs of preterm and term labor, labor process and anxieties about labor, fetal
development, and methods to assess fetal well-being
Ascertain whether woman is planning to attend childbirth preparation classes and what she knows
about the control of discomfort during labor
o A review of the woman’s physical systems is appropriate at each visit, and any suggestive signs or symptoms
are assessed in depth
o Woman’s knowledge of and success with self-management measures are assessed, as well as outcomes of
prescribed therapy
o Physical examination
Re-evaluation is a constant aspect of a pregnant woman’s care
BP: taken at every visit using the same arm and with the woman seated
Evaluated on basis of absolute values and the length of gestation and is interpreted in light of
modifying factors
Prehypertensive: 120-139/80-89mmHg
HTN: 140/90mmHg
Midpregnancy: 125/75mmHg or more bad!
Late pregnancy: 130/85mmHg or more bad!
Rise in systolic by 30mmHg or rise in diastolic by 15mmHg over baseline is significant
finding regardless of absolute values
Weight: measured and appropriateness of the weight gain is evaluated in relation to BMI
Urine, presence of edema
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Document Summary

Visualization of fetus by real-time ultrasound examination: 5-6 weeks. Fetal heart tones detected by ultrasound: 6 weeks. Visualization of fetus by radiographic study: 16 weeks. Fetal heart tones detected by doppler ultrasound stethoscope: 8-17 weeks. Fetal heart tones detected by fetal stethoscope: 17-19 weeks. As family members learn their new roles, periods of tension and conflict may occur. Nursing interventions: promoting effective communication patterns between expectant mother and own mother and between expectant mother and her partner. Most important person to the pregnant woman is usually the father of her child nurtured by partner, has fewer emotional and physical symptoms, fewer labor and childbirth complications, and easier postpartum adjustment. 2 major needs from partner: feeling loved and values and having child accepted. Sex: during first trimester the woman"s sexual desire may decrease especially if breast tenderness, nausea, fatigue, or sleepiness: relationship with fetus.

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