Focus of Care Initial Prenatal Visit First Trimester Second Trimester Third Trimester
Laboratory and Diagnostic Studies
Prenatal Education and Anticipatory Guidance
Group B Streptococcus screening:
• Vaginal and rec- tal swab cultures done at 35–37 weeks on all pregnant women Additional screen- ing testing:
H&H if not done recently in second trimester
(See Appendix C for normal laboratory values in pregnancy.) Repeat if indicated (and not done in late second trimester):
• GC
• Chlamydia
• RPR
• HIV
• HbSAg 1-hour glucose challenge test 24–28 weeks Ultrasound as indicated
Provide information to the woman and her support person on the following:
• Physical changes and common discomforts to Triple screen or
quad screen at 15–20 weeks Ultrasound as indicated
Screening for ges- tational diabetes with 1- hour glu- cose challenge test at 24–28 weeks Hemoglobin and hematocrit (See Appendix C for normal labora- tory values in pregnancy.) Antibody screen if Rh-negative around 26–28 weeks
• Administration of RhoGAM at 28 weeks if Rh-negative and antibody screen negative
Provide information to the woman and her support person on the following:
• Physical changes and common dis- comforts to Review labs
Same as for initial visit
Nutrition assessment
• Height and weight to calculate BMI
• 24-hour diet recall Physical activity level Psychosocial assessment (see Chapter 5)
Depression
Assessment for intimate partner violence Blood type and Rh factor Antibody screen Complete blood count (CBC) including:
• Hemoglobin
• Hematocrit
• Red blood cell count (RBC)
• White blood cell count (WBC)
• Platelet count (See Appendix C for normal laboratory values in pregnancy.)
RPR, VDRL (syphilis serology)
HIV screen
Hepatitis B screen (surface antigen)
Genetic screening based on family history racial or ethnic background (e.g., sickle cell disease, Tay-Sachs) Rubella titer
PPD (tuberculosis screen) Urinalysis
Urine culture and sensitivity Pap smear
Gonorrhea and Chlamydia cultures Ultrasound
Provide information to the woman and her support person on the following:
• Physical changes and common discomforts to expect during first trimester
C H A P T E R 4 ■ Physiological Aspects of Antepartum Care 85
CLINICAL PATHWAY FOR PRENATAL CARE: CONTENT AND TIMING OF ROUTINE PRENATAL VISITS FOR NORMAL PREGNANCY—cont’d
Focus of Care Initial Prenatal Visit First Trimester Second Trimester Third Trimester expect during third trimester
• Relief measures for normal and com- mon discomforts
• Fetal development and growth dur- ing third trimester
• Reinforce warning/
danger signs to report to care provider
• Nutritional follow-up and rec- ommendation of increase in daily caloric intake by 452 kcal/day
• Follow-up on modifiable risk patterns Teach fetal move- ment kick counts Continue teaching and preparing the couple for delivery
• Discussion on attending child- birth preparation classes
• Teach signs of impending labor
• Discuss true vs.
false labor
• Instruction on when to contact the care provider or go to birthing unit
• Discussion on attending parent- ing classes
• Select the method of infant feeding
• Select the infant health care provider
• Preparation of siblings expect during
second trimester
• Relief measures for common dis- comforts
• Fetal develop- ment and growth during second trimester
• Reinforce warning/
danger signs to report to care provider
• Nutritional fol- low-up and rec- ommendation of increase in daily caloric intake by 340 kcal/day
• Follow-up on physical activity as needed
• Follow-up on modifiable risk patterns
• Begin teaching on preparing for birth
• Relief measures for com- mon discomforts
• Fetal development
• General health mainte- nance/health promotion
• Warning/Danger signs to report to care provider
• Nutrition, prenatal vita- mins, and folic acid
• Exercise
• Self-care and modifying behaviors to reduce risks
• Physiology of pregnancy
• Course of care
The Psycho-Social-Cultural Aspects of the Antepartum
Period 5
Nursing Diagnoses
䊏 At risk for anxiety and fear related to:
䊏 unknown processes of pregnancy 䊏 changes in roles related to pregnancy 䊏 changes in family dynamics
䊏 changes in body image
䊏 Knowledge deficit related to pregnancy emotional/physical changes
䊏 At risk for impaired adjustment related to role changes in pregnancy
䊏 At risk for interrupted family processes related to develop- mental stressors of pregnancy
䊏 At risk for impaired communication related to cultural differences between family and health care providers 䊏 Risk for ineffective coping related to inadequate social
support during pregnancy
Nursing Outcomes
The pregnant woman and her family will:
䊏 Be able to communicate effectively with health care providers
䊏 Verbalize decreased anxiety
䊏 Verbalize appropriate family dynamics
䊏 Report increasing acceptance of changes in body image 䊏 Seek clarification of information about pregnancy and birth 䊏 Demonstrate knowledge regarding expected changes of
pregnancy
䊏 Develop a realistic birth plan 䊏 Exhibit acceptance of roles as parents 䊏 Identify appropriate support systems 䊏 Receive positive and effective social support
䊏 Express satisfaction with health care providers’ sensitivity to traditional beliefs and practices of her culture.
EXPECTED STUDENT OUTCOMES
On completion of this chapter, the student will be able to:
䊐 Describe expected emotional changes of the pregnant woman and appropriate nursing responses to these changes.
䊐 Identify the major developmental tasks of pregnancy as they relate to maternal, paternal, and family adaptation.
䊐 Identify critical variables that influence adaptation to pregnancy, including age, parity, and social and cultural factors.
䊐 Identify nursing assessments and interventions that promote positive psycho-social-cultural adapta- tions for the pregnant woman and her family.
䊐 Analyze critical factors in preparing for birth, including choosing a provider, birth setting, and creating a birth plan.
䊐 Identify key components of childbirth preparation education for expectant families.
䊐 Analyze and critique current evidence-based research in the area of psycho-social-cultural adaptation to pregnancy.
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M
ATERNAL ADAPTATION TO PREGNANCY The news of pregnancy confers profound and irrevocable changes in a woman’s life and the lives of those around her.With this news, the woman begins her journey towards becoming a mother. Less visible than the physical adaptations of pregnancy, but just as profound, the pregnant woman’s psychological adaptations and development of her identity as a mother are crucial aspects of the childbearing cycle.
Psychological, cultural, and social variables all significantly influence this process. Psychosocial support for the pregnant woman and her family is a distinct and major nursing respon- sibility during the antepartum period. This chapter presents the expected emotional changes a woman and her family must navigate to achieve a positive adaptation to pregnancy.
Factors influencing these changes are also described.
Successful adaptation to the maternal role requires important psychological work. Although becoming a mother has been noted to occur on a long-term continuum, the psy- chological groundwork is laid during the course of each woman’s individual experience during pregnancy. The preg- nant woman is able to use the 9 months available to her to restructure her psychological and cognitive self towards motherhood. Motherhood, an irrevocable change in a woman’s life, progressively becomes part of a woman’s total identity (Koniak-Griffin, Logsdon, Hines, & Turner, 2006;
Mercer, 1995, 2004).
Maternal Tasks of Pregnancy
Maternal tasks of pregnancy were first identified in the psychoanalytic literature (Bibring, Dwyer, Huntington, &
Valenstein, 1961), then further explored and outlined by classic maternity nurse researchers Reva Rubin, Ramona Mercer, and Regina Lederman. Rubin’s research has pro- vided a framework and core knowledge base from which researchers and clinicians have worked. Rubin identified significant maternal tasks women undergo during the course of pregnancy on their journey towards motherhood (1975, 1984).
■ Ensuring a safe passage for herself and her child refers to the mother’s knowledge and care-seeking behaviors to ensure that both she and the newborn emerge from preg- nancy healthy.
■ Ensuring social acceptance of the child by significant others refers to the woman engaging her social network in the pregnancy.
■ Attaching or “binding-in” to the child refers to the devel- opment of maternal-fetal attachment.
■ Giving of oneself to the demands of being a mother refers to the mother’s willingness and efforts to make personal sacrifices for the child.
Building on Rubin’s work, Regina Lederman (1996, 2009) identified seven dimensions of maternal role development.
These are:
■ Accepting the pregnancy
This task focuses on the woman’s adaptive responses to the changes that occur related to pregnancy growth and develop- ment (Lederman, 1996). These responses include:
■ Responding to mood changes
■ Responding to ambivalent feelings.
■ Responding to nausea, fatigue, and other physical discom- forts of the early months of pregnancy.
■ Responding to financial concerns
■ Responding to increased dependency needs Expected findings:
■ Desire and/or acceptance of pregnancy (see Critical Component: Ambivalent Feelings Toward Pregnancy)
■ Predominately happy feelings during pregnancy
■ Little physical discomfort or a high tolerance for the discomfort
■ Acceptance of body changes
■ Minimal ambivalent feelings and conflict regarding pregnancy by the end of her pregnancy
■ A dislike of being pregnant but a feeling of love for the unborn child.
CRITICAL COMPONENT
Ambivalent Feelings Toward Pregnancy
It is common for women to experience ambivalent feelings toward pregnancy during the first trimester. These feelings decrease as pregnancy progresses. Ambivalence that continues into the third trimester may indicate unresolved conflict. When evaluating ambivalence it is important to assess:
■ The reason for the ambivalence
■ The intensity of the ambivalence
■ Identification with the motherhood role
Accomplishment of this task is influenced by the woman’s acceptance of pregnancy and the relationship the woman has with her own mother. Women who have accep - ted their pregnancy and who have a positive relationship with their own mothers have an easier time accomplishing this task (Lederman, 1996). Accomplishment of this task is also influenced by the woman’s degree of fears about labor related to helplessness, pain, loss of control, and loss of self- esteem (Lederman, 1996). Vivid dreams are common during pregnancy, which allows the woman to envision herself as a mother in various situations. A woman often rehearses or pictures herself in her new role in different scenarios (Rubin, 1975). The motherhood role is progressively strengthened as she attaches to the fetus. Events that facilitate fetal attachment:
■ Hearing the fetal heartbeat
■ Seeing the fetus move during an ultrasound examination
■ Feeling the fetus kick or move
■ Fetal attachment influences the woman’s sense of her child and her sense of being competent as a mother.
C H A P T E R 5 ■ The Psycho-Social-Cultural Aspects of the Antepartum Period 89 Expected Findings:
The woman:
■ Moves from viewing herself as a woman-without-child to a woman-with-child
■ Anticipates changes motherhood will bring to her life
■ Seeks company of other pregnant women
■ Is highly motivated to assume the motherhood role
■ Actively prepares for the motherhood role
■ Relationship to her mother
■ A woman’s relationship with her mother is an important determinant of adaptation to motherhood. Unresolved mother-daughter conflicts re-emerge and can confront women during pregnancy (Lederman, 1996).
Four components important to the woman’s relationship with her own mother are:
■ Availability of the woman’s mother to her in the past and in the present
■ The mother’s reaction to her daughter’s pregnancy
■ The mother’s relationship to her daughter
■ The mother’s willingness to reminisce with her daughter about her own childbirth and child-rearing experiences Expected Findings
■ The woman’s mother was available to her in the past and continues to be available during the pregnancy (Fig. 5-1).
■ The woman’s mother accepts the pregnancy, respects her autonomy, and acknowledges her daughter becoming a mother.
■ The woman’s mother relates to her daughter as an adult versus as a child.
■ The woman’s mother reminisces about her own childbear- ing and child-rearing experiences.
■ Re-ordering relationships with her partner
Pregnancy has a dramatic effect on a couple’s relationship.
Some couples view pregnancy and childbirth as a growth expe- rience and as an expression of deep commitment to their bond, while others view it as an added stressor to a relationship already in conflict. The partner’s support during pregnancy enhances the woman’s feelings of well-being and is associated with earlier and continuous prenatal care (Lederman, 1996, 2009). Feeling loved and valued and having her child accepted by her partner are two major contributors to positive adapta- tion (Cannella, 2006; Orr, 2004). Assessment of the relation- ship between the couple includes:
■ The partner’s concern for the woman’s needs during pregnancy
■ The woman’s concerns for her partner’s needs during pregnancy
■ The varying desire for sexual activity among pregnant women
■ The effect pregnancy has on the relationship (e.g., does it being them closer together or cause conflict?)
■ The partner’s adjustment to his or her new role.
Expected Findings
■ The partner is understanding and supportive of the woman.
■ The partner is thoughtful and “pampers” the woman during pregnancy.
■ The partner is involved in the pregnancy.
■ The woman perceives that her partner is supportive.
■ The woman is concerned about her partner’s needs of making emotional adjustments to the pregnancy and new role. Women in relationships with established open com- munication about sexuality are likely to have less difficulty with changes in sexual activity.
■ Couples indicate that they are growing closer to each other during pregnancy.
■ The partner is happy and excited about the pregnancy and prepares for the new role.
■ Preparation for labor
Preparation for labor means preparation for the physiologi- cal processes of labor as well as the psychological processes of separating from the fetus and becoming a mother to the child.
Preparation for labor and birth occur by taking classes, reading, fantasizing, and dreaming about labor and birth (Lederman, 1996, 2009). The degree of preparation for labor and birth has an effect on the woman’s level of anxiety and fear. The more prepared a woman feels, the lower the level of anxiety and fear.
Expected Findings
■ The woman attends childbirth classes and reads books about labor and birth.
■ The woman mentally rehearses (fantasizes) the labor and birthing process.
■ The woman has dreams about labor and birth.
■ The woman develops realistic expectations of labor and birth.
Figure 5–1 Pregnant woman and her mother participating in baby shower.
■ The pregnant woman may engage in a flurry of activity known as “nesting behavior,” hurrying to finish preparing for the newborn’s arrival (Driscoll, 2008).
■ Prenatal fear of loss of control in labor
Loss of control includes two factors (Lederman 1996, 2009):
■ Loss of control over the body
■ Loss of control over emotions The degree of fear is related to:
■ The woman’s degree of trust with the medical and nursing staff, her partner, and other support persons
■ The woman’s attitude regarding the use of medication and anesthesia for labor pain management
Expected Findings
■ The woman perceives individual attention from medical staff.
■ The woman perceives that she is being treated as an adult and her questions and concerns are addressed by the medical staff.
■ The woman perceives that the nursing staff is compassion- ate, understanding, and available.
■ The woman perceives that she is being supported by her partner and family/friends.
■ The woman has realistic expectations regarding manage- ment of labor pain and these expectations are met.
■ Prenatal fear of loss of self-esteem in labor
Some women have fears that they will lose self-esteem in labor and “fail” during labor (Lederman, 2009). When a woman feels a threat to her self-esteem, it is important to assess the following areas (Lederman, 2009):
■ The source of the threat
■ The response to the threat
■ The intensity of the reaction to the threat Behaviors that reflect self-esteem are:
■ Tolerance of self
■ Value of self and assertiveness
■ Positive attitude regarding body image and appearance Expected Findings
■ Able to develop realistic expectations of self during labor and birth and an awareness of risks and potential complications
■ Able to identify and respect her own feelings
■ Able to assert herself in acquiring information needed to make decisions
■ Able to recognize her own needs and limitations
■ Able to adjust to the unexpected and unknown
■ Able to recover from threats quickly
As the woman prepares to experience labor, give birth, and take on the maternal role, the process of maternal adaptation to pregnancy is completed. With the dominating physical dis- comforts of the third trimester, most women become impa- tient for labor to begin. There is relief and excitement about
going into labor. The mother is ready and eager to deliver and hold her baby. She has prepared for her future as a mother (Rubin, 1984).
Nursing Actions
During the antepartal period, the nurse can take on a variety of roles: teacher, counselor, clinician, resource person, role model (see Critical Component: Nursing Actions That Facilitate Adaptation to Pregnancy).
■ Nursing actions should be focused on health promotion, individualized care, and prevention of individual and family crises (Driscoll, 2008; Matson & Smith, 2004;
Lederman, 2009).
Factors That Influence Maternal Adaptation
The ability of the woman to adapt to the maternal role is influenced by a variety of factors, including parity, maternal age, sexual orientation, single parenting, multiple gestation (twins, triples), socioeconomic factors, and abuse.
Multiparity
■ Multigravidas may have the benefit of experience, but it should not be assumed that they need less help than a first-time mother. They know more of what to expect in terms of pain during labor, postpartum adaptation, and the many added responsibilities of motherhood, but they may need time to process and develop strategies for inte- grating a new member into the family.
■ Pregnancy tasks may be more complex. Giving adequate attention to all of her children and supporting sibling adaptation are unique challenges faced by the multi- gravida. She may spend a great deal of time working out a new relationship with the first child, and grieve for the loss of their special relationship. She also has to consider the financial issues associated with feeding, clothing, and providing for another child while at the same time maintaining a relationship with her partner and continuing her career, whether inside or outside the home (Jordan, 1989).
Maternal Age
■ Adolescent Mothers
Adolescents who have an unintended pregnancy face a number of challenges, including abandonment by their partners, increased adverse pregnancy outcomes, and inabil- ity to complete school education, which may ultimately limit their future social and economic opportunities (Ehiri, Meremikwu, & Meremikwu, 2005). The major developmental task of adolescence is to form and become comfortable with a sense of self. Pregnancy presents a chal- lenge for teenagers who, as expectant parents, must cope with the conflicting developmental tasks of pregnancy and adolescence at the same time. Achieving a maternal identity is very difficult for an adolescent who is in the throes of evolving her own identity as an adult capable of psychosocial independence from her family. Although she may achieve
C H A P T E R 5 ■ The Psycho-Social-Cultural Aspects of the Antepartum Period 91
CRITICAL COMPONENT
may be more anxious about body changes in the second trimester. The woman may begin to have fears or phobias. The nurse needs to acknowledge and validate the woman’s feel- ings, and help the woman work towards resolving any conflict- ing feelings.
■ Discuss normal changes in sexual activity and provide informa- tion and acknowledge the woman’s sexuality.
■ Encourage “tuning in” to fetal movements; discuss fetal capac- ities for hearing, responding to interaction, and maternal activ- ity. This will encourage the attachment process, and help empower the woman with increased involvement in care.
■ Reinforce to partner and family the importance of giving the expectant mother extra support; give specific examples of ways to help (helping her eat well, helping with heavy work, giving extra attention). This will encourage family and partner partic- ipation in the pregnancy process and promote support for the woman. A well-supported woman will likely have a more pos- itive adaptation to pregnancy.
Third Trimester
■ Encourage attendance at childbirth classes to promote knowl- edge and decrease fears.
■ Discuss preparations for birth, parenthood; explore expecta- tions of labor. The woman will begin to focus more on the impending birth during the third trimester, and her learning needs will be more focused on this area. It is important to pro- vide anticipatory information and guidance.
■ Assess partner’s comfort level with labor coach role and reas- sure as needed; stress that help in labor will be available;
encourage presence of second support person if appropriate.
The woman’s partner may not feel comfortable providing labor support, and it is important to discuss prior to the onset of labor so all roles can be clarified.
■ Refer to appropriate educational materials on parenthood.
Encourage discussions of plans, expectations with partner.
Give anticipatory guidance regarding the realities of infant care, breastfeeding, and so on. This will promote communica- tion and planning with the expectant parents, as well as a pos- itive transition to parenthood.
■ If psychosocial complications develop, plan for appropriate referrals to coordinate with social workers, nutritionist, and community agencies to ensure continuity of psychosocial assessment and provide appropriate support during the woman’s pregnancy.
■ Help expectant mother identify and use support systems to promote positive adaptation to pregnancy, birth, and post- partum. To anticipate the need for postpartum support, and decrease the risk of postpartum depression.
Nursing Actions That Facilitate Adaptation to Pregnancy
First Trimester:
■ Begin psychosocial assessment at initial contact; assess woman’s response to pregnancy; assess stressors in woman’s life. It allows the nurse to determine whether there are issues that may require referrals, and to begin to develop the plan of care.
■ Promote pregnancy and birth as a family experience; encourage family and father or partner participation in prenatal visits;
encourage questions from father and family members about the pregnancy. It is important to offer an inclusive model of care that acknowledges the needs of the family as well as the individual.
Pregnancy significantly affects all family members. Meeting with family members provides additional information to the nurse, and helps to complete the family assessment. Positive family support is associated with positive maternal adaptation.
■ Assess learning needs. It allows the nurse to provide individu- alized information.
■ Offer anticipatory guidance regarding normal developmental stressors of pregnancy, such as ambivalence during early preg- nancy, feelings of vulnerability, mood changes, and active dream/fantasy life. It allows the nurse to emphasize normalcy, health, universality, strengths, and developmental concepts, to decrease anxiety.
■ Assess for increased anxieties and fear; if anxieties seem greater than normal, refer to psych care provider. Excessive anxiety and stress, and prenatal depression have a negative impact on the course of a woman’s pregnancy and also affect the physiology of the developing fetus. Specialized interven- tion is needed.
■ Listen, validate, provide reassurance, and teach expected emo- tional changes. Educate partner and family members, and stress normalcy of feelings to decrease anxiety and ensure the woman feels “heard” and validated.
■ If appropriate, discuss common phases through which expec- tant fathers progress through pregnancy. Be aware of phases of paternal adaptation when counseling parents about expect- ed changes of pregnancy; provide anticipatory guidance regarding potential communication conflicts. This will acknowledge the partner as a significant participant in the pregnancy process, and assist in improving communication and decreasing stress in the relationship.
Second Trimester:
■ Encourage verbalization regarding possible grief process dur- ing pregnancy related to body image changes, loss of old life, changing relationships with family and friends. The woman
(Driscoll, 2008; Lederman, 2009; Simpson & Creehan, 2008; Mattson & Smith, 2010)
the maternal role, research indicates that she functions at a lower level of competence than do older women (Mercer, 2004). The younger she is, the more difficulty the adoles- cent woman has with body image changes, acknowledging the pregnancy, seeking health care, and planning for the changes that pregnancy and parenting will bring. Delayed entry into prenatal care is common. There is also a higher
rate of abuse among pregnant adolescents (Montgomery, 2003; Porter, 2011). Successful adaptation to pregnancy and parenthood may greatly depend on the age of the adolescent (Fig. 5-2).
■ Comprehensive and community-based health care pro- grams for adolescents have been shown to be effective in