PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

Intramuros, Manila
College of Nursing
MCN1 2022-2023
Unit 3A

UNIT 3A- CARE OF THE MOTHER AND FETUS

OBJECTIVES

1. Describe the growth and development of a fetus by gestational age in weeks.

2. Identify 2020 National Health Goals addressing fetal growth and development and address how
nurses can help the nation achieve these goals.

3. Assess fetal growth and development through maternal and pregnancy landmarks.

4. Formulate nursing diagnoses related to the needs of a fetus.

5. Establish expected outcomes to meet the perceived needs of a growing fetus as well as manage a
seamless transition from fetus to newborn.

6. Using the nursing process, plan nursing care that includes the six competencies of Quality & Safety
Education for Nurses (QSEN): Patient-Centered Care, Teamwork & Collaboration, Evidence-Based
Practice (EBP), Quality Improvement (QI), Safety, and Informatics.

7. Implement nursing care to help ensure both a safe fetal environment and a safe pregnancy outcome.

8. Evaluate expected outcomes for achievement and effectiveness of care.

9. Integrate knowledge of fetal growth and development with the interplay of nursing process, the six
competencies of QSEN, and Family Nursing to promote quality maternal and child health nursing care.

TO HELP ENSURE FETAL HEALTH

ASSESSMENT

Assessing fetal growth throughout pregnancy, by measuring fundal height and fetal heart rate, is
important because these signs of fetal development provide guidelines for determining the well-being of
a fetus. For the expectant family, knowledge about fetal growth and development can help a woman
understand some of the changes going on in her body as well as allow all family members to begin
thinking about and accepting a new member to their family. For this reason, assessing fetal
development at prenatal visits and conveying the findings are important, providing the family in as much
detail as parents’ request.

NURSING DIAGNOSIS

Common nursing diagnoses related to growth and development of the fetus focus on the pregnant
woman and the family as well as the fetus. Examples might include:
  Readiness for enhanced knowledge related to usual fetal development
 Anxiety related to lack of fetal movement
 Deficient knowledge related to the need for good prenatal care for healthy fetal
well-being.

OUTCOME IDENTIFICATION AND PLANNING

Plans for care should include ways to educate potential parents about teratogens (i.e., any substance
harmful to a fetus) that have the potential to interfere with fetal health. Outcome criteria established
for teaching about fetal growth should be realistic and based on the parents’ previous knowledge and
desire for information. When additional assessment measures are necessary, such as an amniocentesis
or an ultrasound examination, add this information to the teaching plan, explaining why further
assessment is necessary and what the parents can expect from the procedure.

IMPLEMENTATION

Most expectant parents are interested in learning about how mature their fetus is at various points in
pregnancy as this helps them visualize their expected newborn. This, in turn, helps them to understand
the importance of implementing healthy behaviors, such as eating well and avoiding substances that
may be dangerous to a fetus such as recreational drugs. Viewing a sonogram and learning the fetal sex is
a big step toward helping initiate bonding between the parents and the infant. Remember each
woman’s pregnancy is unique to her; be certain implementations are individualized for each woman for
the best chance of outcome success.

OUTCOME EVALUATION

An outcome evaluation related to fetal growth and development usually focuses on determining
whether a woman or family has made any changes in lifestyle necessary to ensure fetal growth and
whether a woman voices confidence that her baby is healthy and growing. Examples of expected
outcomes include:

• Parents describe smoke-free living by next prenatal visit.

• Patient records number of movements fetus makes during 1 hour daily.

• Couple attends all scheduled prenatal visits.

• Patient states she is looking forward to the birth of her baby.

The Nursing Role and Nursing Care During Normal Pregnancy and Birth.

Attending to the psychological and physiologic changes of pregnancy assures the health of the mother,
and a healthy mother is a positive predictor for a healthy baby. A pregnant woman’s body systems
undergo specific changes during pregnancy to support the growth of the fetus. Accurate evaluation of
these changes through assessment of the pregnant woman and her family will help you identify those
changes that require an intervention . You can foster a healthy outcome by obtaining a complete history
and providing a physical examination that focuses on those components that influence fetal
development. Vital signs are monitored following a recommended interval during pregnancy. Prenatal
visits include standard guidelines, which may be altered if a pregnancy is at risk due to complications.
Nursing care for the laboring mother, postpartum care for the mother and newborn , and newborn care
of the term infant decrease the need for interventions.

A. ANTEPARTAL CARE
1. THE GROWING FETUS
a. Stages of fetal development
In just 38 weeks, a fertilized egg (ovum) matures from a single cell to a fully developed
fetus ready to be born. Although different cultures or religions debate the point at
which life begins, for ease of discussion, all agree fetal growth and development can be
divided into three time periods:
• Pre-embryonic (first 2 weeks, beginning with fertilization)
• Embryonic (weeks 3 through 8)
• Fetal (from week 8 through birth)
Table 9.1 lists common terms used to describe the fetus at various stages in this
growth.

FERTILIZATION: THE BEGINNING OF PREGNANCY

Fertilization (also referred to as conception and impregnation) is the union of an ovum
and a spermatozoon. This usually occurs in the outer third of a fallopian tube, termed
the ampullar portion.

Usually, only one of a woman’s ova reaches maturity each month. Once the mature
ovum is released (i.e., ovulation), fertilization must occur fairly quickly because an
ovum is capable of fertilization for only about 24 hours (48 hours at the most). After
that time, it atrophies and becomes nonfunctional. Because the functional life of a
spermatozoon is also about 48 hours, possibly as long as 72 hours, the total critical time
span during which sexual relations must occur for fertilization to be successful is about
72 hours (48 hours before ovulation plus 24 hours afterward).

As the ovum is extruded from the graafian follicle of an ovary with ovulation, it is
surrounded by a ring of mucopolysaccharide fluid (the zona pellucida) and a circle of
cells (the corona radiata). The ovum and these surrounding cells (which increase the
bulk of the ovum and serve as protective buffers against injury) are propelled into a
nearby fallopian tube by currents initiated by the fimbriae—the fine, hairlike structures
that line the openings of the tubes. A combination of peristaltic action of the tube and
movements of the tube cilia help propel the ovum along the length of the tube.

Normally, an ejaculation of semen averages 2.5 ml of fluid containing 50 to 200

million spermatozoa per milliliter or an average of 400 million sperm per ejaculation
(Welliver, Benson, Frederick, et al., 2016). At the time of ovulation, there is a reduction
in the viscosity (thickness) of the woman’s cervical mucus, which makes it easy for
spermatozoa to penetrate it. Sperm transport is so efficient close to ovulation that
spermatozoa deposited in the vagina generally reach the cervix within 90 seconds and
the outer end of a fallopian tube within 5 minutes after deposition.

The mechanism whereby spermatozoa are drawn toward an ovum is probably a

species-specific reaction, similar to an antibody–antigen reaction. Spermatozoa move
through the cervix and the body of the uterus and into the fallopian tube, toward a
waiting ovum by the combination of movement by their flagella (tails) and uterine
contractions.

All of the spermatozoa that reach the ovum cluster around its protective layer of
corona cells. Hyaluronidase (a proteolytic enzyme) is released by the spermatozoa and
dissolves the layer of cells protecting the ovum. Under ordinary circumstances, only one
spermatozoon is able to penetrate the cell membrane of the ovum. Once it penetrates
the cell, the cell membrane changes composition to become impervious to other
spermatozoa. An exception to this is the formation of gestational trophoblastic disease
in which multiple sperm enter an ovum; this leads to abnormal zygote formation
(DiGiulio, Wiedaseck, & Monchek, 2012) .

Immediately after penetration of the ovum, the chromosomal material of the ovum
and spermatozoon fuse to form a zygote. Because the spermatozoon and ovum each
carried 23 chromosomes (22 autosomes and 1 sex chromosome), the fertilized ovum
has 46 chromosomes. If an X-carrying spermatozoon entered the ovum, the resulting
child will have two X chromosomes and will be assigned female at birth (XX). If a Y-
chromosome and will be assigned male at birth (XY).

Fertilization is never a certain occurrence because it depends on at least three

separate factors:
• Equal maturation of both sperm and ovum
• Ability of the sperm to reach the ovum
• Ability of the sperm to penetrate the zona pellucida and cell membrane and
achieve fertilization

Out of this single-cell fertilized ovum (zygote), the future child and also the
accessory structures needed for support during intrauterine life (placenta, fetal
membranes, amniotic fluid, and umbilical cord) will form.

IMPLANTATION
Once fertilization is complete, a zygote migrates over the next 3 to 4 days toward the
body of the uterus, aided by the currents initiated by the muscular contractions of the
fallopian tubes. During this time, mitotic cell division, or cleavage, begins. The first
cleavage occurs at about 24 hours; cleavage divisions continue to occur at a rate of
about one every 22 hours so by the time the zygote reaches the body of the uterus; it
consists of 16 to 50 cells. Over the next 3 or 4 days, large cells tend to collect at the
periphery of the ball, leaving a fluid space surrounding an inner cell mass. At this stage,
the structure is termed a blastocyst. The cells in the outer ring are trophoblast cells.
They are the part of the structure that will later form the placenta and membranes. The
inner cell mass (embryoblast cells) is the portion of the structure that will form the
embryo.

Implantation, or contact between the growing structure and the uterine

endometrium, occurs approximately 8 to 10 days after fertilization. About 8 days after
ovulation, the blastocyst sheds the last residues of the corona and zona pellucida,
brushes against the rich uterine endometrium (in the second [secretory] phase of the
menstrual cycle), and settles down into its soft folds. The stages to this point are
depicted in Figure 9.1.

Implantation usually occurs high in the uterus on the posterior surface. If the point
of implantation is low in the uterus, the growing placenta may occlude the cervix and
make birth of the child difficult (placenta previa) because the placenta can block the
birth canal. Almost immediately, the blastocyst burrows deeply into the endometrium
and establishes an effective communication network with the blood system of the
endometrium. Once implanted, the zygote is called an embryo.

Implantation is an important step in pregnancy because as many as 50% of zygotes

never achieve it (Gardosi, 2012). In these instances, the pregnancy ends as early as 8 to
10 days after conception, often before a woman is even aware she was pregnant.
Occasionally, a small amount of vaginal spotting appears on the day of implantation
because capillaries are ruptured by the implanting trophoblast cells. A woman who
normally has a particularly scant menstrual flow could mistake implantation bleeding
for her menstrual period. If this happens, the predicted date of birth of her baby (based
on the time of her last menstrual period) will be calculated 4 weeks late.

Embryonic and Fetal Structures

The placenta and membranes, which will serve as the fetal lungs, kidneys, and digestive
tract in utero as well as help provide protection for the fetus, begin growth in early
pregnancy in coordination with embryo growth.

THE DECIDUA OR UTERINE LINING

After fertilization, the corpus luteum in the ovary continues to function rather than
atrophying under the influence of human chorionic gonadotropin (hCG) secreted by the
trophoblast cells. This hormone also causes the uterine endometrium to continue to
grow in thickness and vascularity instead of sloughing off as in a usual menstrual cycle.
The endometrium is now typically termed the decidua (the Latin word for “falling off”)
because it will be discarded after birth of the child.

CHORIONIC VILLI
As early as the 11th or 12th day after fertilization, miniature villi, resembling probing
fingers and termed chorionic villi, reach out from the trophoblast cells into the uterine
endometrium to begin formation of the placenta. Chorionic villi have a central core
consisting of connective tissue and fetal capillaries surrounded by a double layer of
cells, which produce various placental hormones, such as hCG, somatomammotropin
(human placental lactogen [hPL]), estrogen, and progesterone. The middle layer, the
cytotrophoblast or Langhans’ layer, appears to have a second function to protect the
growing embryo and fetus from certain infectious organisms such as the spirochete of
syphilis early in pregnancy. Because this layer of cells disappears between the 20th and
24th week of pregnancy, this is why syphilis is not considered to have a high potential
for fetal damage early in pregnancy, only after the point at which cytotrophoblast cells
are no longer present. The layer appears to offer little protection against viral invasion
at any point, increasing the vulnerability of the fetus to viruses (Stohl & Satin, 2011).

THE PLACENTA
The placenta (Latin for “pancake,” which is descriptive of its size and appearance at
term) grows from a few identifiable trophoblastic cells at the beginning of pregnancy to
an organ 15 to 20 cm in diameter and 2 to 3 cm in depth, covering about half the
surface area of the internal uterus at term (Huppertz & Kingdom, 2012).

Circulation
As early as the 12th day of pregnancy,maternal blood begins to collect in the intervillous
spaces of the uterine endometrium surrounding the chorionic villi. By the third week,
oxygen and other nutrients such as glucose, amino acids, fatty acids, minerals, vitamins,
and water osmose from the maternal blood through the cell layers of the chorionic villi
into the villi capillaries. From there, nutrients are transported to the developing embryo.

Placental transfer is dynamic, allowing all but a few substances to cross from the
mother into the fetus. Because almost all drugs are able to cross into the fetal
circulation, it is important that a woman take no nonessential drugs (including alcohol
and nicotine) during pregnancy (Ordean, Kahan, Graves, et al., 2015). For example,
alcohol perfuses across the placenta and may cause fetal alcohol spectrum disorder
(e.g., unusual facial features, low-set ears, and cognitive challenge). Because it’s difficult
to tell what quantity is “safe,” pregnant women are advised to drink no alcohol during
pregnancy to avoid these disorders (Rogers & Worley, 2012).

Theoretically, because the exchange process depends on osmosis, there is no direct

exchange of blood cells between the embryo and the mother during pregnancy.
Occasionally, however, fetal cells do cross into the maternal bloodstream as well as
fetal enzymes such as α-fetoprotein (AFP) produced by the fetal liver (this allows
testing of fetal cells for genetic analysis as well as the level of AFP in the maternal
blood).

As the number of chorionic villi increases with pregnancy, the villi form an
increasingly complex communication network with the maternal bloodstream.
Intervillous spaces grow larger and larger, becoming separated by 30 or more partitions
or septa. These compartments, known as cotyledons, are what make the maternal side
of the placenta look rough and uneven.

To provide enough blood for exchange, the rate of uteroplacental blood flow in
pregnancy increases from about 50 ml/min at 10 weeks to 500 to 600 ml/min at term.
No additional maternal arteries appear after the first 3 months of pregnancy; instead, to
accommodate the increased blood flow, the arteries increase in size. The woman’s heart
rate, total cardiac output, and blood volume all increase to supply blood to the placenta
(Pipkin, 2012). Braxton Hicks contractions, the barely noticeable uterine contractions
present from about the 12th week of pregnancy on, aid in maintaining pressure in the
intervillous spaces by closing off the uterine veins momentarily with each contraction.

Uterine perfusion and placental circulation are most efficient when the mother lies
on her left side, as this position lifts the uterus away from the inferior vena cava,
preventing blood from becoming trapped in the woman’s lower extremities. If the
woman lies on her back and the weight of the uterus compresses on the vena cava,
known as vena cava syndrome, placental circulation can be so sharply reduced that
supine hypotension (i.e., very low maternal blood pressure and poor uterine circulation)
can occur (Coad & Dunstall, 2011a).

At term, the placental circulatory network has grown so extensively that a placenta
weighs 400 to 600 g (1 lb), one-sixth the weight of the newborn. If a placenta is smaller
than this, it suggests circulation to the fetus may have been compromised and/or
inadequate. A placenta bigger than this also may indicate circulation to the fetus was
threatened because it suggests the placenta was forced to spread out in an unusual
manner to maintain a sufficient blood supply. The fetus of a woman with diabetes may
also develop a larger than usual placenta from excess fluid collected between cells.
Endocrine Function
Besides serving as the source of oxygen and nutrients for the fetus, the syncytial (outer)
layer of the chorionic villi develops into a separate and important hormone-producing
system.

Human Chorionic Gonadotropin

The first placental hormone produced, hCG, can be found in maternal blood and urine
as early as the first missed menstrual period (shortly after implantation has occurred).
Levels vary throughout pregnancy. The pregnant woman’s blood serum will be
completely negative for hCG within 1 to 2 weeks after birth. Finding no serum hCG
after birth can be used as proof that placental tissue is no longer present.

hCG’s purpose is to act as a fail-safe measure to ensure the corpus luteum of the
ovary continues to produce progesterone and estrogen so the endometrium of the
uterus is maintained. hCG also may play a role in suppressing the maternal immunologic
response so placental tissue is not detected and rejected as a foreign substance.
Because the structure of hCG is similar to that of luteinizing hormone of the pituitary
gland, if the fetus is male, it exerts an effect on the fetal testes to begin testosterone
production and maturation of the male reproductive tract (Huppertz & Kingdom, 2012).

At about the eighth week of pregnancy, the outer layer of cells of the developing
placenta begins to produce progesterone, making the corpus luteum, which was
producing progesterone, no longer necessary. In coordination with this, the production
of hCG, which sustained the corpus luteum, begins to decrease at this point.

Progesterone
Estrogen is often referred to as the “hormone of women,” and progesterone as the
“hormone that maintains pregnancy.” This is because, although estrogen influences a
female appearance, progesterone is necessary to maintain the endometrial lining of the
uterus during pregnancy. It is present in maternal serum as early as the fourth week of
pregnancy as a result of the continuation of the corpus luteum. After placental
production begins (at about the 12th week), the level of progesterone rises
progressively during the remainder of the pregnancy. This hormone also appears to
reduce the contractility of the uterus during pregnancy, thus preventing premature
labor.

Estrogen
Estrogen (primarily estriol) is produced as a second product of the syncytial cells of the
placenta. Estrogen contributes to the woman’s mammary gland development in
preparation for lactation and stimulates uterine growth to accommodate the developing
fetus.

Human Placental Lactogen (Human Chorionic Somatomammotropin)

hPL is a hormone with both growth-promoting and lactogenic (i.e., milk-producing)
properties. It is produced by the placenta beginning as early as the sixth week of
pregnancy, increasing to a peak level at term. It promotes mammary gland (breast)
growth in preparation for lactation in the mother. It also serves the important role of
regulating maternal glucose, protein, and fat levels so adequate amounts of these
nutrients are always available to the fetus.

Placental Proteins
In addition to hormones, the placenta also produces a number of plasma proteins. The
function of these has not been well documented, but they may contribute to decreasing
the immunologic impact of the growing placenta and help prevent hypertension of
pregnancy (Song, Li, & An, 2015).

THE AMNIOTIC MEMBRANES

The chorionic villi on the medial surface of the trophoblast (i.e., those that are not
involved in implantation because they do not touch the endometrium) gradually thin
until they become the chorionic membrane, the outermost fetal membrane. The
amniotic membrane, or amnion, forms beneath the chorion (Fig. 9.3). The amniotic
membrane is a dual-walled sac with the chorion as the outmost part and the amnion as
the innermost part. The two fuse together as the pregnancy progresses, and by term,
they appear to be a single sac. They have no nerve supply, so when they spontaneously
rupture at term (a pregnant woman’s “water breaks”) or are artificially ruptured via a
procedure, neither the pregnant woman nor fetus experiences any pain (Coad &
Dunstall, 2011b).

Figure 9.3 Membranes, with embryo lying within amniotic sac.

In contrast to the chorionic membrane, the second membrane (the amniotic

membrane) not only offers support to amniotic fluid but also actually produces the fluid.
In addition, it produces a phospholipid that initiates the formation of prostaglandins,
which may be the trigger that initiates labor.

THE AMNIOTIC FLUID

Amniotic fluid never becomes stagnant because it is constantly being newly formed and
absorbed by direct contact with the fetal surface of the placenta. The major method of
absorption, however, happens within the fetus. Because the fetus continually swallows
the fluid, it is absorbed from the fetal intestine into the fetal bloodstream. From there, it
goes to the umbilical arteries and to the placenta and is exchanged across the placenta
to the mother’s bloodstream.

At term, the amount of amniotic fluid has grown so much it ranges from 800 to
1,200 ml. If for any reason the fetus is unable to swallow (esophageal atresia or
anencephaly are the two most common reasons), excessive amniotic fluid or
hydramnios (more than 2,000 ml in total or pockets of fluid larger than 8 cm on
ultrasound) will result (Ghionzoli, James, David, et al., 2012). Hydramnios may also
occur in women with diabetes because hyperglycemia causes excessive fluid shifts into
the amniotic space (Perović, Garalejić, Gojnić, et al., 2012).

Early in fetal life, as soon as the fetal kidneys become active, fetal urine adds to the
quantity of the amniotic fluid. A disturbance of kidney function, therefore, may cause
oligohydramnios or a reduction in the amount of amniotic fluid. Oligohydramnios can
be detected by ultrasound. The amniotic fluid index is measured, and it should be at
least 5 cm. The vertical pocket of amniotic fluid should be greater than 2 cm (American
Congress of Obstetricians and Gynecologists [ACOG], 2014). The appropriate amount
of amniotic fluid ensures adequate kidney function.

The most important purpose of amniotic fluid is to shield the fetus against pressure
or a blow to the mother’s abdomen. Because liquid changes temperature more slowly
than air, it also protects the fetus from changes in temperature. Another function is that
it aids in muscular development, as amniotic fluid allows the fetus freedom to move.
Finally, it protects the umbilical cord from pressure, thus protecting the fetal oxygen
supply.

Even if the amniotic membranes rupture before birth and the bulk of amniotic fluid
is lost, some will always surround the fetus in utero because new fluid is constantly
being formed. Amniotic fluid is slightly alkaline, with a pH of about 7.2. Checking the
pH of the fluid at the time membranes rupture and amniotic fluid is released helps to
differentiate amniotic fluid from urine because urine is acidic (pH 5.0 to 5.5).

THE UMBILICAL CORD

The umbilical cord is formed from the fetal membranes, the amnion and chorion, and
provides a circulatory pathway that connects the embryo to the chorionic villi of the
placenta. Its function is to transport oxygen and nutrients to the fetus from the placenta
and to return waste products from the fetus to the placenta. It is about 53 cm (21 in.) in
length at term and about 2 cm (0.75 in.) thick. The bulk of the cord is a gelatinous
mucopolysaccharide called Wharton jelly, which gives the cord body and prevents
pressure on the vein and arteries that pass through it.

An umbilical cord contains only one vein (carrying blood from the placental villi to
the fetus) and two arteries (carrying blood from the fetus back to the placental villi). The
number of veins and arteries in the cord is always assessed and recorded at birth
because about 1% to 5% of infants are born with a cord that contains only a single vein
and artery. Of these infants, 15% to 20% are found to have accompanying chromosomal
disorders or congenital anomalies, particularly of the kidney and heart (Schneider,
2011).

The rate of blood flow through an umbilical cord is rapid (350 ml/min at term). The
adequacy of blood flow (blood velocity) through the cord, as well as both systolic and
diastolic cord pressure, can be determined by ultrasound examination. Counting the
number of coils in the cord may be used as a prediction of healthy fetal growth, as
hypocoiling is associated with maternal hypertension and hypercoiling is associated
with respiratory distress in the newborn (Chitra, Sushanth, & Raghavan, 2012).

Because the rate of blood flow through the cord is so rapid, it is unlikely a knot or
twist in the cord will interfere with the fetal oxygen supply. In about 20% of all births, a
loose loop of cord is found around the fetal neck (nuchal cord) at birth (Hoh, Sung, &
Park, 2012). If this loop of cord is removed before the newborn’s shoulders are born
(not usually hard to do) so there is no traction on it, the oxygen supply to the fetus
remains unimpaired.

The walls of the umbilical cord arteries are lined with smooth muscle. When these
muscles contract after birth, the cord arteries and vein are compressed to prevent
hemorrhage of the newborn through the cord. Because the umbilical cord contains no
nerve supply, it can be clamped and cut at birth without discomfort to either the child or
mother.

Origin and Development of Organ Systems

Following the moment of fertilization, the zygote, which later becomes an embryo and
then a fetus, begins to grow at an active pace.

STEM CELLS
During the first 4 days of life, zygote cells are termed totipotent stem cells, or cells so
undifferentiated they have the potential to grow into any cell in the human body. In
another 4 days, as the structure implants and becomes an embryo, cells begin to show
differentiation or lose their ability to become any body cell. Instead, they are slated to
become specific body cells, such as nerve, brain, or skin cells, and are termed
pluripotent stem cells. In yet another few days, the cells grow so specific they are
termed multipotent, or are so specific they cannot be deterred from growing into a
particular body organ such as spleen or liver or brain (Chen, Sun, Li, et al., 2016).

ZYGOTE GROWTH
As soon as conception has taken place, development proceeds in a cephalocaudal
(head-to-tail) direction; that is, head development occurs first and is followed by
development of the middle and, finally, the lower body parts. This pattern of
development continues after birth as shown by the way infants are able to lift up their
heads approximately 1 year before they are able to walk.

PRIMARY GERM LAYERS

As a fetus grows, body organ systems develop from specific tissue layers called germ
layers. At the time of implantation, the blastocyst already has differentiated to a point
at which three separate layers of these cells are present: the ectoderm, the endoderm,
and the mesoderm (see Fig. 9.1). Each of these germ layers develops into specific body
systems (Table 9.2). Knowing which structures arise from each germ layer is helpful to
know because coexisting congenital disorders found in newborns usually arise from the
same germ layer. For example, a fistula between the trachea and the esophagus (both
of which arise from the endoderm layer) is a common birth anomaly. In contrast, it is
rare to see a newborn with a malformation of the heart (which arises from the
mesoderm) and also a malformation of the lower urinary tract (which arises from the
endoderm). One reason rubella infection is so serious in pregnancy is because this virus
is capable of infecting all three germ layers so can cause congenital anomalies in a
myriad of body systems (White, Boldt, Holditch, et al., 2012).

All organ systems are complete, at least in a rudimentary form, at 8 weeks gestation
(the end of the embryonic period). During this early time of organogenesis (organ
formation), the growing structure is most vulnerable to invasion by teratogens (i.e., any
factor that affects the fertilized ovum, embryo, or fetus adversely, such as a teratogenic
medicine; an infection such as toxoplasmosis; cigarette smoking; or alcohol ingestion).
Figure 9.4 illustrates critical periods of fetal growth when it is most
important for women to minimize their exposure to teratogens.
CARDIOVASCULAR SYSTEM
The cardiovascular system is one of the first systems to become functional in
intrauterine life. Simple blood cells joined to the walls of the yolk sac progress to
become a network of blood vessels and a single heart tube, which forms as early as the
16th day of life and beats as early as the 24th day. The septum that divides the heart
into chambers develops during the sixth or seventh week; heart valves develop in the
seventh week. The heartbeat may be heard with a Doppler instrument as early as the
10th to 12th week of pregnancy. An electrocardiogram (ECG) may be recorded on a
fetus as early as the 11th week, although early ECGs are not accurate until conduction is
more regulated at about the 20th week of pregnancy.
The heart rate of a fetus is affected by oxygen level, activity, and circulating blood
volume, just as in adulthood. After the 28th week of pregnancy, when the sympathetic
nervous system matures, the heart rate stabilizes, and a consistent heart rate of 110 to
160 beats/min is assessed.

Fetal Circulation
Fetal circulation differs from extrauterine circulation because the fetus derives
oxygen and excretes carbon dioxide not from gas exchange in the lungs but from
exchange in the placenta.

Blood arriving at the fetus from the placenta is highly oxygenated. This blood enters
the fetus through the umbilical vein (which is still called a vein even though it carries
oxygenated blood because the direction of the blood is toward the fetal heart).
Specialized structures present in the fetus then shunt blood flow to first supply the most
important organs of the body: the liver, heart, kidneys, and brain. Blood flows from the
umbilical vein to the ductus venosus, an accessory vessel that discharges oxygenated
blood into the fetal liver, and then connects to the fetal inferior vena cava so
oxygenated blood is directed to the right side of the heart. Because there is no need for
the bulk of blood to pass through the lungs, the bulk of this blood is shunted as it enters
the right atrium into the left atrium through an opening in the atrial septum called the
foramen ovale. From the left atrium, it follows the course of adult circulation into the
left ventricle, then into the aorta, and out to body parts.

A small amount of blood that returns to the heart via the vena cava does leave the
right atrium by the adult circulatory route; that is, through the tricuspid valve into the
right ventricle and then into the pulmonary artery and lungs to service the lung tissue.
However, the larger portion of even this blood is shunted away from the lungs through
an additional structure, the ductus arteriosus, directly into the descending aorta.

As the majority of blood cells in the aorta become deoxygenated, blood is

transported from the descending aorta through the umbilical arteries (which are called
arteries because they carry blood away from the fetal heart) back through the umbilical
cord to the placental villi, where new oxygen exchange takes place.

At birth, an infant’s oxygen saturation level is 95% to 100% and pulse rate is 80 to
140 beats/min. Because there is a great deal of mixing of blood in the fetus, the oxygen
saturation level of fetal blood reaches only about 80%. A normal fetal heart rate is 110
to 160 beats/min, supplying needed oxygen to cells. Even with this low blood oxygen
saturation level, however, carbon dioxide does not accumulate in the fetal system
because it rapidly diffuses into maternal blood across a favorable placental pressure
gradient.

Fetal Hemoglobin
Fetal hemoglobin differs from adult hemoglobin in several ways. It has a different
composition (two α and two γ chains compared with two α and two β chains of adult
hemoglobin). It is also more concentrated and has greater oxygen affinity, two features
that increase its efficiency. Because hemoglobin is more concentrated, a newborn’s
hemoglobin level is about 17.1 g/100 ml compared with a normal adult level of 11
g/100 ml; a newborn’s hematocrit is about 53% compared with a normal adult level of
45%. The change from fetal to adult hemoglobin levels begins before birth (γ cells are
exchanged for β cells), but the process is still not complete at birth. Major blood
dyscrasias, such as sickle cell anemia, tend to be defects of the β-hemoglobin chain,
which is why clinical symptoms of these disorders do not become apparent until the
bulk of fetal hemoglobin has matured to adult hemoglobin, at about 6 months of age
(Panepinto & Scott, 2011).

RESPIRATORY SYSTEM
At the third week of intrauterine life, the respiratory and digestive tracts exist as a single
tube. Like all body tubes, initially, this forms as a solid structure, which then canalizes
(i.e., hollows out). By the end of the fourth week, a septum begins to divide the
esophagus from the trachea. At the same time, lung buds appear on the trachea.

Until the seventh week of life, the diaphragm does not completely divide the
thoracic cavity from the abdomen. This causes lung buds to extend down into the
abdomen, reentering the chest only as the chest’s longitudinal dimension increases and
the diaphragm becomes complete (at the end of the seventh week). If the diaphragm
fails to close completely, the stomach, spleen, liver, or intestines may be pulled up into
the thoracic cavity. This causes the child to be born with intestine present in the chest
(i.e., diaphragmatic hernia), compromising the lungs and perhaps displacing the heart
(Gowen, 2011).

Other important respiratory developmental milestones include:

• Spontaneous respiratory practice movements begin as early as 3 months gestation
and continue throughout pregnancy.
• Specific lung fluid with a low surface tension and low viscosity forms in alveoli
to aid in expansion of the alveoli at birth; it is rapidly absorbed shortly after birth.
• Surfactant, a phospholipid substance, is formed and excreted by the alveolar
cells of the lungs beginning at approximately the 24th week of pregnancy. This
decreases alveolar surface tension on expiration, preventing alveolar collapse and
improving the infant’s ability to maintain respirations in the outside environment
at birth (Rojas-Reyes, Morley, & Soll, 2012).

Surfactant has two components: lecithin and sphingomyelin. Early in the formation
of surfactant, sphingomyelin is the chief component. At approximately 35 weeks, there
is a surge in the production of lecithin, which then becomes the chief component by a
ratio of 2:1. As a fetus practices breathing movements, surfactant mixes with amniotic
fluid. Using an amniocentesis technique, an analysis of the lecithin/sphingomyelin (L/S)
ratio in surfactant (whether lecithin or sphingomyelin is the dominant component) is a
primary test of fetal maturity. Respiratory distress syndrome, a severe breathing
disorder, can develop if there is a lack of surfactant or it has not changed to its mature
form at birth.

Any interference with the blood supply to the fetus, such as placental insufficiency
or maternal hypertension, may raise steroid levels in the fetus and enhance surfactant
development. Synthetically increasing steroid levels in the fetus (e.g., the administration
of betamethasone to the mother late in pregnancy) can also hurry alveolar maturation
and surfactant production without interfering with permanent lung function prior to a
preterm birth (Smith, 2016).

NERVOUS SYSTEM
Like the circulatory system, the nervous system begins to develop extremely early in
pregnancy.
• A neural plate (a thickened portion of the ectoderm) is apparent by the third week
of gestation. The top portion differentiates into the neural tube, which will form
the central nervous system (brain and spinal cord), and the neural crest, which
will develop into the peripheral nervous system.
• All parts of the brain (cerebrum, cerebellum, pons, and medulla oblongata) form
in utero, although none are completely mature at birth. Brain growth continues at
high levels until 5 or 6 years of age.
• Brain waves can be detected on an electroencephalogram (EEG) by the eighth
week.
• The eye and inner ear develop as projections of the original neural tube.
• By 24 weeks, the ear is capable of responding to sound, and the eyes exhibit a
pupillary reaction, indicating sight is present.
The neurologic system seems particularly prone to insult during the early weeks of
the embryonic period and can result in neural tube disorders, such as a meningocele
(i.e., herniation of the meninges), especially if there is lack of folic acid (which is
contained in green leafy vegetables and pregnancy vitamins) (Cohen & Uddin, 2011).
All during pregnancy and at birth, the system is vulnerable to damage if anoxia should
occur.

ENDOCRINE SYSTEM
The function of endocrine organs begins along with neurosystem development.
• The fetal pancreas produces insulin needed by the fetus (insulin is one of the few
substances that does not cross the placenta from the mother to the fetus).
• The thyroid and parathyroid glands play vital roles in fetal metabolic function
and calcium balance.
• The fetal adrenal glands supply a precursor necessary for estrogen synthesis by
the placenta.

DIGESTIVE SYSTEM
The digestive tract separates from the respiratory tract at about the fourth week of
intrauterine life and, after that, begins to grow extremely rapidly. Initially solid, the tract
canalizes (hollows out) to become patent. Later in the pregnancy, the endothelial cells
of the gastrointestinal tract proliferate extensively, occluding the lumen once more, and
the tract must canalize again. Atresia (blockage) or stenosis (narrowing) of the track are
common fetal anomalies and develop if either the first or second canalization does not
occur (Lin, Munsie, Herdt-Losavio, et al., 2012). The proliferation of cells shed in the
second recanalization forms the basis for meconium (see following discussion).

Because of this rapid intestinal growth, by the sixth week of intrauterine life, the
intestine becomes too large to be contained by the abdomen. A portion of the intestine,
therefore, is pushed into the base of the umbilical cord, where it remains until about the
10th week of intrauterine life or until the abdominal cavity has grown large enough to
accommodate the bulky intestines. As intestine returns to the abdominal cavity at this
point, it must rotate 180 degrees. Failure to do so can result in inadequate mesentery
attachments, possibly leading to volvulus of the intestine in the newborn.

If any intestine remains outside the abdomen in the base of the cord, a congenital
anomaly, termed omphalocele, will be present at birth. A similar defect, gastroschisis,
occurs when the original midline fusion that occurred at the early cell stage is
incomplete (Hay, Levin, Deterding, et al., 2016).

Meconium, a collection of cellular wastes, bile, fats, mucoproteins,

mucopolysaccharides, and portions of the vernix caseosa (i.e., the lubricating substance
that forms on the fetal skin), accumulates in the intestines as early as the 16th week.
Meconium is sticky in consistency and appears black or dark green (obtaining its color
from bile pigment). An important neonatal nursing responsibility is recording that a
newborn has passed meconium as this rules out a stricture (noncanalization) of the anus
(Marcelis, de Blaauw, & Brunner, 2011).

The gastrointestinal tract is sterile before birth. Because vitamin K, necessary for
blood clotting, is synthesized by the action of bacteria in the intestines, vitamin K levels
are almost nonexistent in a fetus and are still low in a newborn (vitamin K is routinely
administered intramuscularly at birth). Sucking and swallowing reflexes are not mature
until the fetus is approximately 32 weeks gestation, or weighs 1,500 g. However, strong
suck and swallowing reflexes may not be present until the fetus is full term.

The ability of the gastrointestinal tract to secrete enzymes essential for carbohydrate
and protein digestion is mature at 36 weeks. However, amylase, an enzyme found in
saliva and necessary for digestion of complex starches, does not mature until 3 months
after birth. Many newborns have also not yet developed lipase, an enzyme needed for
fat digestion (a reason breast milk is the best food for newborns because its digestion
does not depend on these enzymes).

The liver is active throughout intrauterine life, functioning as a filter between the
incoming blood and the fetal circulation and as a deposit site for fetal stores such as iron
and glycogen. Unfortunately, during intrauterine life, the fetal liver is unable to prevent
recreational drugs or alcohol ingested by the mother from entering the fetal circulation
and possibly causing birth anomalies (Singer, Moore, Fulton, et al., 2012). Newborns
need careful assessment at birth for hypoglycemia (low blood sugar) and
hyperbilirubinemia (excessive breakdown products from destroyed red blood cells), two
serious problems that can occur in the first 24 hours after birth because, although
active, liver function is still immature.

MUSCULOSKELETAL SYSTEM
During the first 2 weeks of fetal life, cartilage prototypes provide position and support
to the fetus. Ossification of this cartilage into bone begins at about the 12th week and
continues all through fetal life and into adulthood. Carpals, tarsals, and sternal bones
generally do not ossify until birth is imminent. A fetus can be seen to move on
ultrasonography as early as the 11th week, although the mother usually does not feel
this movement (quickening) until 16 to 20 weeks of gestation. It is usually felt earlier in
multigravida women.

REPRODUCTIVE SYSTEM
A child’s sex is determined at the moment of conception by a spermatozoon carrying an
X or a Y chromosome and can be ascertained as early as 8 weeks by chromosomal
analysis or analysis of fetal cells in the mother’s bloodstream. At about the sixth week
after implantation, the gonads (i.e., ovaries or testes) form. If testes form, testosterone
is secreted, apparently influencing the sexually neutral genital duct to form other male
organs (i.e., maturity of the wolffian, or mesonephric, duct). In the absence of
testosterone secretion, female organs will form (i.e., maturation of the müllerian, or
paramesonephric, duct). This is an important phenomenon because if a woman should
unintentionally take an androgen or an androgen-like substance during this stage of
pregnancy, a child who is chromosomally female could appear more male than female
at birth. If deficient testosterone is secreted by the testes, both the müllerian (female)
duct and the wolffian (male) duct could develop (i.e., pseudohermaphroditism, or
intersex) (Kutney, Konczal, Kaminski, et al., 2016).

The testes first form in the abdominal cavity and do not descend into the scrotal sac
until the 34th to 38th week of intrauterine life. Because of this, many male preterm
infants are born with undescended testes. These boys need a follow-up to be certain
their testes do descend when they reach what would have been the 34th to 38th week
of gestational age because testicular descent does not always occur as readily in
extrauterine life as it would have in utero. Testes that do not descend (cryptorchidism)
require surgery as they are associated with poor sperm production and possibly
testicular cancer later in life (Kelsey, Barker, Bartz, et al., 2016).

URINARY SYSTEM
Although rudimentary kidneys are present as early as the end of the fourth week of
intrauterine life, the presence of kidneys does not appear to be essential for life before
birth because the placenta clears the fetus of waste products. Urine, however, is formed
by the 12th week and is excreted into the amniotic fluid by the 16th week of gestation.
At term, fetal urine is being excreted at a rate of up to 500 ml/day. An amount of
amniotic fluid less than usual (oligohydramnios) suggests fetal kidneys are not secreting
adequate urine and that there is a kidney, ureter, or bladder disorder (Kumar, 2012).

The complex structure of the kidneys gradually develops during intrauterine life and
continues to mature for months afterward. The loop of Henle, for example, is not fully
differentiated until the fetus is born. Glomerular filtration and concentration of urine in
the newborn are still not efficient because the ability to concentrate urine is still not
mature at birth. Early in the embryonic stage of urinary system development, the
bladder extends as high as the umbilical region, and there is an open lumen between
the urinary bladder and the umbilicus. If this fails to close, (termed a patent urachus),
this is revealed at birth by the persistent drainage of a clear, acid–pH fluid (urine) from
the umbilicus (Samra, McGrath, & Wehbe, 2011).

INTEGUMENTARY SYSTEM
The skin of a fetus appears thin and almost translucent until subcutaneous fat begins to
be deposited underneath it at about 36 weeks. Skin is covered by soft downy hairs
(lanugo) that serve as insulation to preserve warmth in utero as well as a cream cheese–
like substance, vernix caseosa, which is important for lubrication and for keeping the
skin from macerating in utero. Both lanugo and vernix are still present at birth.

IMMUNE SYSTEM
Immunoglobulin (Ig) G maternal antibodies cross the placenta into the fetus as early as
the 20th week and certainly by the 24th week of intrauterine life to give a fetus
temporary passive immunity against diseases for which the mother has antibodies.
These often include poliomyelitis, rubella (German measles), rubeola (regular measles),
diphtheria, tetanus, infectious parotitis (mumps), hepatitis B, and pertussis (whooping
cough). Infants born before this antibody transfer has taken place have no natural
immunity and so need more than the usual protection against infectious disease in the
newborn period.

A fetus only becomes capable of active antibody production late in pregnancy.

Generally, it is not necessary for a fetus to produce antibodies because they need to be
manufactured only to counteract an invading antigen, and antigens rarely invade the
intrauterine space. Because IgA and IgM antibodies (the types which develop to
actively counteract infection) cannot cross the placenta, their presence in a newborn is
proof that the fetus has been exposed to an infection.
MILESTONES OF FETAL GROWTH AND DEVELOPMENT
When fetal milestones occur can be confusing because the life of the fetus is typically
measured from the time of ovulation or fertilization (ovulation age), but the length of a
pregnancy is more commonly measured from the first day of the last menstrual period
(gestational age). Because ovulation and fertilization take place about 2 weeks after the
last menstrual period, the ovulation age of the fetus is always 2 weeks less than the
length of the pregnancy or the gestational age.

Both ovulation and gestational age are typically reported in lunar months (4-week
periods) or in trimesters (3-month periods) rather than in weeks. In lunar months, a
total pregnancy is 10 months (40 weeks or 280 days) long; a fetus grows in utero for 9.5
lunar months or three full trimesters (38 weeks or 266 days).

The following discussion of fetal developmental milestones is based on gestational

weeks because it is helpful when talking to expectant parents to correlate fetal
development with the way they measure pregnancy—from the first day of the last
menstrual period. Figure 9.6 illustrates the comparative size and appearance of human
embryos and fetuses at different stages of development.

End of Fourth Gestational Week

• The length of the embryo is about 0.75 cm; weight is about 400 mg.
• The spinal cord is formed and fused at the midpoint.
• The head is large in proportion and represents about one third of the entire
structure.
• The rudimentary heart appears as a prominent bulge on the anterior surface.
• Arms and legs are bud-like structures; rudimentary eyes, ears, and nose are
discernible.

End of Eighth Gestational Week

• The length of the fetus is about 2.5 cm (1 in.); weight is about 20 g.
• Organogenesis is complete.
• The heart, with a septum and valves, beats rhythmically.
• Facial features are definitely discernible; arms and legs have developed.
• External genitalia are forming, but sex is not yet distinguishable by simple
observation.
• The abdomen bulges forward because the fetal intestine is growing so rapidly.
• A sonogram shows a gestational sac, which is diagnostic of pregnancy.

End of 12th Gestational Week (First Trimester)

• The length of the fetus is 7 to 8 cm; weight is about 45 g.
• Nail beds are forming on fingers and toes.
• Spontaneous movements are possible, although they are usually too faint to be
felt by the mother.
• Some reflexes, such as the Babinski reflex, are present.
• Bone ossification centers begin to form.
• Tooth buds are present.
• Sex is distinguishable on outward appearance.
• Urine secretion begins but may not yet be evident in amniotic fluid.
• The heartbeat is audible through Doppler technology.

End of 16th Gestational Week

• The length of the fetus is 10 to 17 cm; weight is 55 to 120 g.
• Fetal heart sounds are audible by an ordinary stethoscope.
• Lanugo is well formed.
• Both the liver and pancreas are functioning.
• The fetus actively swallows amniotic fluid, demonstrating an intact but
uncoordinated swallowing reflex; urine is present in amniotic fluid.
• Sex can be determined by ultrasonography.

End of 20th Gestational Week

• The length of the fetus is 25 cm; weight is 223 g.
• Spontaneous fetal movements can be sensed by the mother.
• Antibody production is possible.
• Hair, including eyebrows, forms on the head; vernix caseosa begins to cover the
skin.
• Meconium is present in the upper intestine.
• Brown fat, a special fat that aids in temperature regulation, begins to form behind
the kidneys, sternum, and posterior neck.
• Passive antibody transfer from mother to fetus begins.
• Definite sleeping and activity patterns are distinguishable as the fetus develops
biorhythms that will guide sleep/wake patterns throughout life.

End of 24th Gestational Week (Second Trimester)

• The length of the fetus is 28 to 36 cm; weight is 550 g.
• Meconium is present as far as the rectum.
• Active production of lung surfactant begins.
• Eyelids, previously fused since the 12th week, now open; pupils react to light.
• Hearing can be demonstrated by response to sudden sound.
• When fetuses reach 24 weeks, or 500 to 600 g, they have achieved a practical
low-end age of viability if they are cared for after birth in a modern intensive care
nursery.

End of 28th Gestational Week

• The length of the fetus is 35 to 38 cm; weight is 1,200 g.
• Lung alveoli are almost mature; surfactant can be demonstrated in amniotic fluid.
• Testes begin to descend into the scrotal sac from the lower abdominal cavity.
• The blood vessels of the retina are formed but thin and extremely susceptible to
damage from high oxygen concentrations (an important consideration when
caring for preterm infants who need oxygen).
End of 32nd Gestational Week
• The length of the fetus is 38 to 43 cm; weight is 1,600 g.
• Subcutaneous fat begins to be deposited (the former stringy, “little old man”
appearance is lost).
• Fetus responds by movement to sounds outside the mother’s body.
• An active Moro reflex is present.
• Iron stores, which provide iron for the time during which the neonate will ingest
only breast milk after birth, are beginning to be built.
• Fingernails reach the end of fingertips.

End of 36th Gestational Week

• The length of the fetus is 42 to 48 cm; weight is 1,800 to 2,700 g (5 to 6 lb).
• Body stores of glycogen, iron, carbohydrate, and calcium are deposited.
• Additional amounts of subcutaneous fat are deposited.
• Sole of the foot has only one or two crisscross creases compared with a full
crisscross pattern evident at term.
• Amount of lanugo begins to diminish.
• Most fetuses turn into a vertex (head down) presentation during this month.

End of 40th Gestational Week (Third Trimester)

• The length of the fetus is 48 to 52 cm (crown to rump, 35 to 37 cm); weight is
3,000 g (7 to 7.5 lb).
• Fetus kicks actively, sometimes hard enough to cause the mother considerable
discomfort.
• Fetal hemoglobin begins its conversion to adult hemoglobin.
• Vernix caseosa starts to decrease after the infant reaches 37 weeks gestation and
may be more apparent in the creases than the covering of the body as the infant
approaches 40 weeks or more gestational age.
• Fingernails extend over the fingertips.
• Creases on the soles of the feet cover at least two thirds of the surface.
In primiparas (i.e., women having their first baby), the fetus often sinks into the
birth canal during the last 2 weeks of pregnancy, giving the mother a feeling the load
she is carrying is less. This event, termed lightening, is a fetal announcement that the
fetus is in a ready position and birth is nearing.

DETERMINATION OF ESTIMATED BIRTH DATE

It is impossible to predict with a high degree of accuracy the exact day an infant will be
born because fewer than 5% of pregnancies end exactly 280 days from the last
menstrual period; fewer than half end within 1 week of the 280th day.
Traditionally, this date was referred to as the estimated date of confinement (EDC).
Because women are no longer “confined” after childbirth, the acronym EDB (estimated
date of birth) is more commonly used today.
If fertilization occurred early in a menstrual cycle, the pregnancy will probably end
“early”; if ovulation and fertilization occurred later than the midpoint of the cycle, the
pregnancy will end “late.” Because of these normal variations, a pregnancy ending 2
weeks before or 2 weeks after the calculated EDB is considered well within the normal
limit (38 to 42 weeks). Gestational age wheels and birth date calculators, which can be
used to predict a birth date are available, but calculation by Naegele’s rule is the
standard method used to predict the length of a pregnancy.

Naegele’s Rule
To calculate the date of birth
To calculate the date of birth by this rule, count backward 3 calendar months from the
first day of a woman’s last menstrual period and add 7 days. For example, if the last
menstrual period began May 15, you would count back 3 months (April 15, March
15, February 15) and add 7 days, to arrive at the predicted date of birth as February
22.

Assessment of Fetal Growth and Development

Tests for fetal growth and development are commonly done for a variety of reasons,
including to:
• Predict the outcome of the pregnancy
• Manage the remaining weeks of the pregnancy
• Plan for possible complications at birth
• Plan for problems that may occur in the newborn infant
• Decide whether to continue the pregnancy
• Find conditions that may affect future pregnancies
Both fetal growth and development can be compromised if a fetus has a metabolic
or chromosomal disorder that interferes with normal growth, if the supporting
structures such as the placenta or cord do not form normally, or if environmental
influences such as the nicotine in cigarettes causes fetal growth restriction (including
testes growth in a male fetus) (Virtanen, Sadov, & Toppari, 2012).

Nursing responsibilities for these assessment procedures include verifying that a

signed consent form has been obtained as needed (which is necessary if the procedure
poses any risk to the mother or fetus that would not otherwise be present), being
certain the woman and her support person are aware of what the procedure will entail
and any potential risks, preparing the woman physically and psychologically, providing
support during the procedure, assessing both fetal and maternal responses during and
after the procedure, providing any necessary follow-up care, and managing equipment
and specimens. Box 9.4 shows an interprofessional care map illustrating both nursing
and team planning for fetal care, including assessment procedures.

HEALTH HISTORY
Like all assessments, a fetal assessment begins with a health history. Ask the mother
specifically about any prepregnancy illnesses such as gestational diabetes or heart
disease because these both can interfere with fetal growth. Ask about any drugs a
woman takes; for instance, common drugs taken for recurrent seizures can be
teratogenic and therefore pose a risk in pregnancy (Mawhinney, Campbell, Craig, et al.,
2012). Inquire about nutritional intake because if a woman is not eating a well-balanced
diet, she may not be taking in enough nutrients for fetal growth (Whitney & Rolfes,
2012). Be certain to also ask about personal habits such as cigarette smoking, both
prescription and recreational drug use, alcohol consumption, and exercise because all of
these may influence glucose/insulin balance and fetal growth. Most women are aware
alcohol ingestion can harm a fetus (e.g., fetal alcohol spectrum disorder) but many are
not yet aware of fetal tobacco syndrome (Wong, Ordean, & Kahan, 2011). This
syndrome applies to the fetus of a woman who smokes more than five cigarettes a day
and who is born growth restricted (i.e., birth weight under 2,500 g at term). Smoking
may also be a cause of ectopic (tubal) pregnancy as fallopian tubes may become
irritated (Shao, Zou, Wang, et al., 2012).

Most women instinctively protect a fetus growing inside them so pregnancy may be
the push they need to improve their lifestyle. Asking if a woman has had any
exposure to teratogens can reveal exposure to such substances as chemicals, paint
fumes, cleaning products, poor air quality, or a loud noise level (Krueger, Horesh, &
Crossland, 2012). Asking about unintentional injuries or intimate partner violence can
help reveal whether the pregnant woman and fetus could have suffered any trauma
from these sources (e.g., intimate partner violence tends to increase during pregnancy
because of the stress a pregnancy can create) (Dalton, 2012).

Nursing Care Planning to Respect Cultural Diversity

Different cultures have different ideas as to what foods to eat, how much exercise is
good during pregnancy, and whether fetal tests for well-being are ethical. Cultural
beliefs also affect everyday things, such as believing it is wrong to have a photograph
pregnant (the origin of lullabies were songs to keep away Lilith, an avenging creature
in Jewish folklore who was thought to bring harm to babies). Believing photographs
are harmful may make a woman reluctant to have a sonogram taken during
pregnancy; unlike most women, she may not like a photograph of the ultrasound for a
baby keepsake.

Some religions also do not support a full range of contraception options; in these
instances, the nurse can assist by recommending other natural family planning
options that align with the woman’s preferences.

PHYSICAL EXAMINATION
A physical examination of the mother is the second step in evaluating fetal health.
Assess maternal weight and general appearance because both obesity and underweight
are clues that the mother’s nutrition may not be adequate for sound fetal growth
(Warren, Rance, & Hunter, 2012). Bruises may indicate intimate partner violence that
could have bruised the fetus as well. An elevated blood pressure may be the beginning
of hypertension of pregnancy, which can restrict fetal growth (Vest & Cho, 2012).

ESTIMATING FETAL HEALTH

A number of procedures, both noninvasive and invasive, are used to evaluate fetal
health. Because there are many procedures, helping a woman with a high-risk
pregnancy maintain a sense of control or empowerment as she is scheduled for them is
an important nursing responsibility .

Nursing Care Planning to Empower a Family

Women may find the names of tests like maternal serum α-fetoprotein (MSAFP) and
substances being tested for (acetylcholinesterase) so confusing that they feel as if
their life is being taken over by scheduled tests or exams. To help a woman maintain
control:
• Encourage her to ask questions until her primary healthcare provider simplifies
instructions or test results enough that she thoroughly understands them.
• Encourage her to set the time and date of appointments if possible so she can fit
fetal testing in with her schedule rather than be expected to appear “on command.”
• Encourage her to bring her significant other with her for fetal testing so he or she
hears the same explanation she does and so that person can also ask questions
rather than hearing the information second hand.
• Don’t refer to a fetus as “it” during testing because that is such an impersonal
term. If the woman has chosen a name, use that while referring to her fetus;
otherwise, use “he or she.”
• Respect modesty during exams where the woman’s abdomen will be exposed.
Movie stars are often pictured today with their pregnant abdomen on view, but not
every woman wants her body exposed unnecessarily that way.
• Remember that late in pregnancy, women’s movements can be painful and may
feel awkward, so respect that asking a woman to step up and lie on an examining
table is not asking her to complete an easy task. Offer help as necessary but also
remember feeling independent is an empowering feeling.

Fetal Growth
As a fetus grows, the uterus expands to accommodate its size. Although not evidence
grounded, typical fundal (top of the uterus) measurements are:
• Over the symphysis pubis at 12 weeks
• At the umbilicus at 20 weeks
• At the xiphoid process at 36 weeks
McDonald’s rule, another symphysis–fundal height measurement (although, again,
not documented to be thoroughly reliable), is an easy method of determining
midpregnancy growth. Typically, tape measurement from the notch of the symphysis
pubis to over the top of the uterine fundus as a woman lies supine is equal to the week
of gestation in centimeters between the 20th and 31st weeks of pregnancy (e.g., in a
pregnancy of 24 weeks, the fundal height should be 24 cm) (Fig. 9.8).
A fundal height much greater than this standard suggests a multiple pregnancy, a
miscalculated due date, a large-for-gestational-age (LGA) infant, hydramnios (increased
amniotic fluid volume), or possibly even gestational trophoblastic disease. A fundal
measurement much less than this suggests the fetus is failing to thrive
(e.g., intrauterine growth restriction), the pregnancy length was miscalculated, or an
anomaly interfering with growth has developed. McDonald’s rule becomes inaccurate
during the third trimester of pregnancy because the fetus is growing more in weight
than in height during this time.

ASSESSING FETAL WELL-BEING

A number of actions or procedures are helpful in detecting and documenting the fetus is
not only growing but also apparently healthy.

Fetal Heart Rate

Fetal heart sounds can be heard and counted as early as the 10th to 11th week of
pregnancy by the use of an ultrasound Doppler technique (Fig. 9.9). This is done
routinely at every prenatal visit past 10 weeks.
Daily Fetal Movement Count (Kick Counts)
Fetal movement that can be felt by the mother (quickening) occurs at approximately 18
to 20 weeks of pregnancy and peaks in intensity at 28 to 38 weeks. After that time, a
healthy fetus moves with a degree of consistency at about 10 times per hour. In
contrast, a fetus who is not receiving enough nutrients because of poor maternal
nutrition or placental insufficiency has greatly decreased movements. The technique for
“kick counts” varies from institution to institution, but a typical method used is to ask
women with high-risk pregnancies to:
• Lie in a left recumbent position after a meal.
• Observe and record the number of fetal movements (kicks) their fetus makes
until they have counted 10 movements.
• Record the time (typically, this is under an hour).
• If an hour passes without 10 movements, they should walk around a little and try
a count again.
• If 10 movements (kicks) cannot be felt in a second 1-hour period, they should
telephone their primary healthcare provider. The fetus could be healthy but
sleeping during this time, so lack of typical movements may not be serious, but it
is an indication for further assessment.

Kick counts are particularly useful in growth-restricted or postterm pregnancies to

reveal if a fetus is still receiving adequate nutrition (Caughey, 2012). Make certain the
woman knows fetal movements do vary, especially in relation to sleep cycles, her
activity, and the time since she last ate. Otherwise, she can become unduly worried her
fetus is in jeopardy when the fetus is asleep or just having an inactive time.

Rhythm Strip Testing

The term “rhythm strip testing” refers to an assessment of fetal well-being and assesses
the fetal heart rate for a normal baseline rate. For this, help the woman into a semi-
Fowler’s position (either in a comfortable lounge chair or on an examining table or bed
with an elevated backrest) to prevent her uterus from compressing the vena cava and
causing supine hypotension syndrome during the test. Attach an external fetal heart
rate monitor abdominally. Record the fetal heart rate for 20 minutes.

The baseline reading refers to the average rate of the fetal heartbeat. Variability
denotes the small changes in rate that occur from second to second if the fetal
parasympathetic nervous system is receiving adequate oxygen and nutrients. In the
rhythm strip in Figure 9.10B, for example, the baseline (average) of the fetal heartbeat
is 130 beats/min. Variability is present.

Long-term variability reflects the state of the fetal sympathetic nervous system. On a
rhythm strip, it is the differences in heart rate that occur over the 20-minute time
period. Note in Figure 9.10B how the heart rate varies from 150 to 130 beats/min.
Because the average fetus moves about twice every 10 minutes, and movement causes
the heart rate to increase, there will typically be two or more instances of fetal heart
rate acceleration in a 20-minute rhythm strip.
Variability is rated as:
• Absent: No peak-to-trough range is detectable.
• Minimal: An amplitude range is detectable but the rate is 5 beats/min or fewer.
• Moderate or normal: An amplitude range is detectable; rate is 6 to 25 beats/min.
• Marked: An amplitude range is detectable; rate is greater than 25 beats/min
(ACOG, 2009).

Rhythm strip testing requires a woman to remain in a fairly fixed position for 20
minutes. Keep her well informed of the importance and purpose of the test and be
certain she understand the meaning of the results after the test. Electronic fetal heart
rate recording is further discussed in Chapter 15 as it can also be used to assess fetal
wellbeing at the beginning of labor.

Nonstress Testing
A nonstress test measures the response of the fetal heart rate to fetal movement.
Position the woman and attach both a fetal heart rate and a uterine contraction
monitor. Instruct the woman to push the button attached to the monitor (similar to a
call bell) whenever she feels the fetus move. This will create a dark mark on the paper
tracing at these times.

When the fetus moves, the fetal heart rate should increase approximately 15
beats/min and remain elevated for 15 seconds. It should decrease to its average rate
again as the fetus quiets (Fig. 9.10C). If no increase in beats per minute is noticeable on
fetal movement, further testing may be necessary to rule out poor oxygen perfusion of
the fetus.

A nonstress test usually is done for 20 minutes. The test is said to be reactive
(healthy) if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15
seconds occur after movement within the time period. The test is nonreactive (fetal
health may be affected) if no accelerations occur with the fetal movements. The results
also can be interpreted as nonreactive if no fetal movement occurs or if there is low
short-term fetal heart rate variability (less than 6 beats/min) throughout the testing
period (Bienstock, Fox, Wallach, et al., 2015).

If a 20-minute period passes without any fetal movement, it may only mean that the
fetus is sleeping, although other reasons for lessened variability are maternal smoking,
drug use, or hypoglycemia. Although not evidence based, if you give the woman an oral
carbohydrate snack, such as orange juice, it can cause her blood glucose level to
increase enough to cause fetal movement. The fetus also may be stimulated by a loud
sound (discussed later) to cause movement.

Because both rhythm strip and nonstress testing are noninvasive procedures and
cause no risk to either the pregnant woman or fetus, they can be used as screening
procedures in all pregnancies. They can be conducted at home daily as part of a home
monitoring program for the woman who is having a complication of pregnancy. If a
nonstress test is nonreactive, an additional fetal assessment, such as a biophysical
profile test, will be scheduled.

Vibroacoustic Stimulation
For acoustic (sound) stimulation, a specially designed acoustic stimulator is applied to
the mother’s abdomen to produce a sharp sound of approximately 80 dB at a frequency
of 80 Hz, thus startling and waking the fetus (Bienstock et al., 2015).

During a standard nonstress test, if a spontaneous acceleration has not occurred

within 5 minutes, apply a single 1- to 2-second sound stimulation to the lower abdomen.
This can be repeated again at the end of 10 minutes if no further spontaneous
movement
occurs, so two movements within the 20-minute window can be evaluated.

Ultrasonography
Ultrasonography, which measures the response of sound waves against solid objects, is
a much-used tool for fetal health assessments. It can be used to:
• Diagnose pregnancy as early as 6 weeks gestation.
• Confirm the presence, size, and location of the placenta and amniotic fluid.
• Establish a fetus is growing and has no gross anomalies such as hydrocephalus;
anencephaly; or spinal cord, heart, kidney, and bladder concerns.
• Establish the sex if a penis is revealed.
• Establish the presentation and position of the fetus.
• Predict gestational age by measurement of the biparietal diameter of the head or
crown-to-rump measurement.
• Discover complications of pregnancy, such as the presence of an intrauterine
device, hydramnios (excessive amniotic fluid) or oligohydramnios (lessened
amniotic fluid), ectopic pregnancy, missed miscarriage, abdominal pregnancy,
placenta previa (a low-implanted placenta), premature separation of the placenta,
coexisting uterine tumors, or multiple pregnancy. Genetic disorders such as
Down syndrome and fetal anomalies such as neural tube disorders, diaphragmatic
hernia, or urethral stenosis also can be diagnosed. Fetal death can be revealed by
a lack of heartbeat and respiratory movement.
• After birth, a sonogram may be used to detect a retained placenta or poor uterine
involution in the new mother.

For an ultrasound, intermittent sound waves of high frequency (above the audible
range) are projected toward the uterus by a transducer placed on the abdomen or in the
vagina. The sound frequencies that bounce back from the fetus can be displayed on an
oscilloscope screen as a visual image. The frequencies returning from tissues of various
thicknesses and properties present distinct appearances. A permanent record can be
made of the scan for the woman’s electronic health record; a copy of the scan can be
offered to her as a baby book souvenir.

Images are so clear that the fetal heart as well as movement of the extremities, such
as bringing a hand to the mouth to suck a thumb, can be seen. A parent who is in doubt
her fetus is well or whole can be greatly reassured by viewing such a sonogram image.

Before an ultrasound examination, be certain a woman has received a good

explanation of what the procedure will be like and reassurance that the process does
not involve X-rays and so will be safe for the fetus (Box 9.7). This means it is also safe for
the father of the child to remain in the room during the test and see the images as well.

The sound waves reflect best if the uterus can be held stable so it is helpful if the
woman has a full bladder at the time of the procedure. To ensure this, ask her to drink a
full glass of water every 15 minutes beginning 90 minutes before the procedure and to
not void until after the procedure.

Help the woman up to an examining table and drape her for modesty, but with her
abdomen exposed. To prevent supine hypotension syndrome, place a towel under her
right buttock to tip her body slightly so the uterus will roll away from the vena cava. A
gel is then applied to her abdomen to improve the contact of the transducer. Be certain
the gel is at room temperature or even slightly warmer or it may cause uncomfortable
uterine cramping. The transducer is then applied to her abdomen and moved both
horizontally and vertically until the uterus and its contents are fully scanned (Fig. 9.11).
Ultrasonography also may be performed using an intravaginal technique, although this
is not necessary for routine testing.

Although the long-term effects of ultrasound are not yet known, the technique
appears to be safe for both mother and fetus and causes no discomfort to the fetus.
Usually, the only discomfort for the woman is the messiness of the contact lubrication
and a strong desire to void before the scan is completed. Taking home a photograph of
the sonographic image can enhance bonding because it is proof the pregnancy exists
and the fetus appears well. As desirable as it is, however, caution women against having
ultrasound images done just for the purpose of having “keepsake” photographs.
Commercial firms offering these services are not well regulated, and their equipment
may be outdated and unsafe.

In medical practice, a number of specific features are studied by sonogram.

Biparietal Diameter
Ultrasonography may be used to predict fetal maturity by measuring the biparietal
diameter (side-to-side measurement) of the fetal head. In 80% of pregnancies in which
the biparietal diameter of the fetal head is 8.5 cm or greater, it can be predicted the
infant will weigh more than 2,500 g (5.5 lb) at birth or is at a fetal age of 40 weeks.
Doppler Umbilical Velocimetry
Doppler ultrasonography measures the velocity at which red blood cells in the uterine
and fetal vessels travel. Assessment of the blood flow through uterine blood vessels is
helpful to determine the vascular resistance present in women with gestational diabetes
or hypertension and whether resultant placental insufficiency is occurring. Decreased
velocity is an important predictor that uterine growth restriction will occur because it
reveals that only a limited number of nutrients are able to reach the fetus (Kaponis,
Harada, Makrydimas, et al., 2011).
Placental Grading for Maturity
Placentas can be graded by ultrasound based on the particular amount of calcium
deposits present in the base. Placentas are graded as:
• 0: between 12 and 24 weeks
• 1: 30 to 32 weeks
• 2: 36 weeks
• 3: 38 weeks (Because fetal lungs are apt to be mature by 38 weeks, a grade 3
placenta suggests the fetus is mature.)

Amniotic Fluid Volume

The amount of amniotic fluid present is yet another way to estimate fetal health
because
a portion of the fluid is formed by fetal kidney output. If a fetus is becoming so stressed
in utero that circulatory and kidney function is failing, urine output and, consequently,
the volume of amniotic fluid will decrease. A decrease in amniotic fluid volume puts the
fetus at risk for compression of the umbilical cord with interference of nutrition as well
as lack of room to exercise and maintain muscle tone. Between 28 and 40 weeks, the
total pockets of amniotic fluid revealed by sonogram average 12 to 15 cm. An amount
greater than 20 to 24 cm indicates hydramnios (i.e., excessive fluid, perhaps caused by
inability of the fetus to swallow). An amount less than 5 to 6 cm indicates
oligohydramnios (i.e., decreased amniotic fluid, perhaps caused by poor perfusion and
kidney failure).

Nuchal Translucency
Children with a number of chromosome anomalies have unusual pockets of fat or fluid
present in their posterior neck, which show on sonograms as nuchal translucency.

Biophysical Profile
A biophysical profile combines five parameters (i.e., fetal reactivity, fetal breathing
movements, fetal body movement, fetal tone, and amniotic fluid volume) into one
assessment. The fetal heart and breathing record measures short-term central nervous
system function; the amniotic fluid volume helps measure long-term adequacy of
placental function. The scoring for a complete profile is shown in Table 9.3. By this
system, each item has the potential for scoring a 2, so 10 would be the highest score
possible. A biophysical profile is more accurate in predicting fetal well-being than any
single assessment (Oyelese & Vintzileos, 2011). Because the scoring system is similar
to an Apgar score determined at birth on infants, it is often referred to as a fetal Apgar
score.
Biophysical profiles may be done as often as daily during a high-risk pregnancy.
The fetal scores are as follows:
• A score of 8 to 10 means the fetus is considered to be doing well.
• A score of 6 is considered suspicious.
• A score of 4 denotes a fetus potentially in jeopardy.
For simplicity, some centers use only two assessments (amniotic fluid index [AFI]
and a nonstress test) for the analysis. Referred to as a modified biophysical profile, this
predicts short-term viability by the nonstress test and long-term viability by the AFI. A
healthy fetus should show a reactive nonstress test and an AFI range between 5 and 25
cm (Bienstock et al., 2015). Nurses play a large role in obtaining the information for
both a modified and a full biophysical profile by obtaining either the nonstress test or
the sonogram reading.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is yet another way to assess a growing fetus.
Because the technique apparently causes no harmful effects to the fetus or woman, MRI
has the potential to replace or complement ultrasonography as a fetal assessment
technique because it can identify structural anomalies or soft tissue disorders
(O’Connor, Rooks, & Smith, 2012). An MRI may be most helpful in diagnosing
complications such as ectopic pregnancy or trophoblastic disease (see Chapter 21)
because later in a pregnancy, fetal movement (unless the fetus is sedated) can obscure
the findings.

Maternal Serum
Because a number of trophoblast cells pass into the maternal bloodstream beginning at
about the seventh week of pregnancy, maternal serum analysis can reveal information
about the pregnant woman as well as the fetus.

Maternal Serum α-Fetoprotein

AFP is a substance produced by the fetal liver that can be found in both amniotic fluid
and maternal serum (maternal serum α-fetoprotein [MSAFP]). The level is abnormally
high if the fetus has an open spinal or abdominal wall defect because the open defect
allows more AFP to enter the mother’s circulation than usual. Although the reason is
unclear, the level is low if the fetus has a chromosomal defect such as Down syndrome.
MSAFP levels begin to rise at 11 weeks gestation and then steadily increase until term.
Traditionally assessed at the 15th week of pregnancy, between 85% and 90% of neural
tube anomalies and 80% of babies with Down syndrome can be detected by this method
(Rogers & Worley, 2012).

Maternal Serum for Pregnancy-Associated Plasma Protein A

Pregnancy-associated plasma protein A (PAPP-A) is a protein secreted by the placenta;
low levels in maternal blood are associated with fetal chromosomal anomalies,
including trisomies 13, 18, and 21 or small-for-gestational-age (SGA) babies. A high
PAPP-A level may predict an LGA baby.
Quadruple Screening
Quadruple screening analyzes four indicators of fetal health: AFP, unconjugated estriol
(UE; an enzyme produced by the placenta that estimates general well-being), hCG (also
produced by the placenta), and inhibin A (a protein produced by the placenta and
corpus luteum associated with Down syndrome).

As with the measurement of MSAFP, quadruple testing requires only a simple

venipuncture of the mother. Because it measures four separate values, it is the most
common of the maternal serum tests used today (Manipalviratn, Trivax, & Huang,
2013).

Fetal Gender
Although fetal gender is usually determined by an ultrasound screen at about 4 months,
it can be determined as early as 7 weeks by analysis of maternal serum. This early
diagnosis could be helpful to a woman who has an X-carrying genetic disorder so she
could discover if she has a male fetus who could inherit the disease or a female fetus
who will be disease-free (Mortarino, Garagiola, Lotta, et al., 2011). Screening of this
type has some ethical connotations because if the fetus is determined to be the
“wrong”
gender, there could be serious consequences for the now unwanted child.

Invasive Fetal Testing

If a genetic or growth concern is identified by noninvasive measures, a number of
invasive measures allow for more refined investigation. Examples include chorionic
villi sampling and amniocentesis (see Chapter 8).
If the woman has Rh-negative blood, Rho(D) immune globulin (RhIG; RhoGAM) is
administered after the procedure to prevent fetal isoimmunization or help ensure
maternal antibodies will not form against any placental red blood cells that might have
accidentally been released into the maternal bloodstream during the procedure.
Amniotic fluid (obtained through amniocentesis, Fig. 9.14) can be analyzed for:
• AFP
• Acetylcholinesterase, another compound that rises to high levels if a neural tube
anomaly is present
• Bilirubin determination. The presence of bilirubin may be analyzed if a blood
incompatibility is suspected. If bilirubin is going to be analyzed, the specimen
must be free of blood or a false-positive reading will occur.
• Chromosome analysis. A few fetal skin cells are always present in amniotic fluid
so these cells may be cultured and stained for karyotyping for genetic analysis.
Examples of genetic diseases that can be detected by prenatal amniocentesis and
their significance to health are discussed in Chapter 7.
• Color. Normal amniotic fluid is the color of water; late in pregnancy, it may have
a slightly yellow tinge. A strong yellow color suggests a blood incompatibility
(the yellow results from the presence of bilirubin released from the breakdown of
red blood cells). A green color suggests meconium staining, a phenomenon
associated with fetal distress.
• Fibronectin. Fibronectin is a glycoprotein that plays a part in helping the placenta
attach to the uterine decidua. Early in pregnancy, it can be assessed in the
woman’s cervical mucus, but the amount then fades until, after 20 weeks of
pregnancy, it is no longer present in cervical mucus. As labor approaches and
cervical dilation begins, it can be found again in cervical or vaginal fluid.
Damage to fetal membranes from cervical dilatation releases a great deal of the
substance, so detection of fibronectin in either the amniotic fluid or in the
mother’s vagina late in pregnancy can serve as an announcement that preterm
labor may be beginning.
• Inborn errors of metabolism. A number of inherited diseases that are caused by
inborn errors of metabolism can be detected by amniocentesis. For a condition to
be identified, an errant enzyme must be present in the amniotic fluid as early as
the time of the procedure. Examples of illnesses that can be detected in this way
are sickle cell disease, cystic fibrosis, muscular dystrophy, Tay-Sachs disease,
and maple syrup urine disease (an amino acid disorder).
• L/S ratio. Lecithin and sphingomyelin are the protein components of the lung
enzyme surfactant that the alveoli begin to form at the 22nd to 24th weeks of
pregnancy. Following an amniocentesis, the L/S ratio may be determined quickly
by a shake test (if bubbles appear in the amniotic fluid after shaking, the ratio is
mature), but the specimen is then sent for laboratory analysis for a definite
analysis. An L/S ratio of 2:1 is traditionally accepted as lung maturity. Infants of
mothers with severe diabetes may have false-mature readings of lecithin because
stress to the infant in utero tends to mature lecithin pathways early. This means
fetal values must be considered in light of the presence of maternal diabetes or
the infants may be born with mature lung function but be immature overall (a
fragile giant), causing them to not do well in postnatal life (Hay et al., 2016).
Some laboratories interpret a ratio of 2.5:1 or 3:1 as a mature indicator in infants
of women with diabetes.
• Phosphatidylglycerol and desaturated phosphatidylcholine. These are additional
compounds, in addition to lecithin and sphingomyelin, found in surfactant.
Pathways for these compounds mature at 35 to 36 weeks. Because they are
present only with mature lung function, if they are present in the sample of
amniotic fluid, it can be predicted with even greater confidence that respiratory
distress syndrome is not likely to occur.
Percutaneous Umbilical Blood Sampling
Percutaneous umbilical blood sampling (PUBS; also called cordocentesis or
funicentesis) is the aspiration of blood from the umbilical vein for analysis. After the
umbilical cord is located by sonography, a thin needle is inserted by amniocentesis
technique into the uterus and is then guided by ultrasound until it pierces the umbilical
vein. A sample of blood is then removed for blood studies, such as a complete blood
count, direct Coombs test, blood gases, and karyotyping. To ensure the blood obtained
is fetal blood, it is submitted to a Kleihauer–Betke test, which measures the difference
between adult and fetal hemoglobin. If a PUBS test reveals that the fetus is anemic,
blood may be transfused into the cord using this same technique. Because the umbilical
vein continues to ooze for a moment after the procedure, there is a high chance fetal
blood could enter the maternal circulation after the procedure, so RhIG is given to
Rhnegative women to prevent sensitization. Fetal heart rate and uterine contractions
need to be monitored before and after the procedure to be certain uterine contractions
are not beginning and also by ultrasound to be certain no bleeding is evident. This
procedure carries little additional risk to the fetus or woman over amniocentesis and
can yield information not available by any other means, especially about blood
dyscrasias.

Fetoscopy
The use of a fetoscopy, in which the fetus is visualized by inspection through a
fetoscope (an extremely narrow, hollow tube inserted by amniocentesis technique), can
be yet another way to assess fetal well-being. This method allows direct visualization of
both the amniotic fluid and the fetus (Richter, Wergeland, DeKoninck, et al., 2012). If a
photograph is taken through the fetoscope, it can document a problem or reassure
parents that their infant is perfectly formed. The main reasons the procedure is used are
to:
• Confirm the intactness of the spinal column.
• Obtain biopsy samples of fetal tissue and fetal blood samples.
• Determine meconium staining is not present.
• Perform elemental surgery, such as inserting a polyethylene shunt into the fetal
ventricles to relieve hydrocephalus or anteriorly into the fetal bladder to relieve a
stenosed urethra. It may be possible to repair a neural tube defect such as
meningocele or improve the outcome of myelomeningocele by fetoscopy
(Danzer, Johnson, & Adzick, 2012).

The earliest time in pregnancy a fetoscopy can be performed is approximately the

16th or 17th week. For the procedure, the mother is draped as for amniocentesis. A
local anesthetic is injected into the abdominal skin. The fetoscope is then inserted
through a minor abdominal incision. If the fetus is very active, meperidine (Demerol)
may be administered to the woman to help sedate the fetus to avoid fetal injury by the
scope and allow for better observation.

A fetoscopy carries a small risk of premature labor or amnionitis (infection of the

amniotic fluid). To avoid infection, the woman may be prescribed antibiotic therapy
after the procedure. The number of procedures performed by a fetoscopy is limited
because of the manipulation involved and the ethical quandary of the mother’s
autonomy being compromised by fetal needs if further procedures are necessary such
as asking the pregnant woman to undergo general anesthesia so the fetus can have
surgery.

Women With Unique Needs or Concerns

Fetal assessment can be more difficult in some women than others. For example, it is
more difficult to hear fetal heart sounds in a morbidly obese woman. If the straps for
fetal heart rate monitors are not long enough to circle a woman’s abdomen, they may
need to be held in place manually. If a woman is not easily mobile, she can have
difficulty obtaining a clean catch urine for protein and glucose testing. Be ready to assist
in these circumstances as needed.

Women who are wheelchair challenged can remain in their wheelchair for fetal heart
rate monitoring. All individuals who use wheelchairs need to periodically press on the
armrests with their hands and raise their buttocks off the seat of the wheelchair to help
prevent pressure ulcers as the danger of ulcers increases with pregnancy because of the
added weight. During a lengthy test, a woman may need to take a break to stretch;
mark the break on a rhythm strip so a sudden corresponding fetal movement on the
strip is not misinterpreted.

Remember that women who are hearing challenged will not be able to hear their
baby’s heartbeat by Doppler assessment. Observing a rhythm strip is a better method to
prove to them their fetus appears healthy. In contrast, a woman who is visually impaired
would be most assured by listening to the beeping of a Doppler rather than the blurry
outlines (for her) of a rhythm strip. Assess each woman individually to be certain each
has obtained and understands the results of fetal assessments accurately and doesn’t
have continuing questions about her baby’s health.

Nursing Care Related to Psychological and

Physiologic Changes of Pregnancy
OBJECTIVES:
1. Describe common psychological and physiologic changes that occur with
pregnancy and the relationship of the changes to pregnancy diagnosis.
2. Identify 2020 National Health Goals related to preconception counseling and
prenatal care that nurses can help the nation achieve.
3. Assess a woman and her support team for psychological adjustment to the
physiologic changes that occur with pregnancy.
4. Formulate nursing diagnoses related to adjustments necessary because of
psychological and physiologic changes of pregnancy.
5. Identify expected outcomes in relation to a family’s psychological and physical
adaptation to pregnancy to help them manage seamless transitions across differing
healthcare settings.
6. Using the nursing process, plan nursing care that includes the six competencies of
Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork
& Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI),
Safety, and Informatics.
7. Implement nursing care, such as health teaching related to the expected changes of
pregnancy.
8. Evaluate outcomes for achievement and effectiveness of goals to be certain
expected outcomes have been achieved.
9. Integrate knowledge of psychological and physiologic changes of pregnancy with
the interplay of nursing process, the six competencies of QSEN, and Family
Nursing to promote quality maternal and child health nursing care.

Patients are often interested in learning more about the physical or psychological
changes that pregnancy brings because these changes both verify the reality and mark
the progress of pregnancy.

Physiologic changes of pregnancy occur gradually but eventually affect all of a

woman’s organ systems. They are necessary changes because they allow a woman’s
body to be able to provide oxygen and nutrients for her growing fetus as well as extra
nutrients for her own increased metabolism. They also ready her body for labor and
birth and for lactation (breastfeeding) once her baby is born (Bernstein & VanBuren,
2013). Despite the magnitude of these changes, such as a woman’s blood volume
doubling in amount, they are all extensions of normal physiology. At the end of
pregnancy, her body will virtually return to its prepregnant state.
Psychological changes of pregnancy occur in response not only to the physiologic
alterations happening but also to the increased responsibility associated with
welcoming a new and completely dependent person to a family.
Because pregnancy changes are extensions of normal psychological and physiologic
baselines, pregnancy represents a time of wellness, not of illness. A major responsibility
for nurses caring for pregnant women and their families is to help the family maintain a
feeling of wellness throughout the pregnancy and into early parenthood (Rogers &
Worley, 2016). Box 10.1 shows 2020 National Health Goals relevant to these changes
that come with pregnancy.

Nursing Process Overview

FOR HEALTHY ADAPTATION TO PREGNANCY
ASSESSMENT
Ideally, assessment for pregnancy begins before the pregnancy with preconception
counseling. During a preconception assessment, evaluate a woman’s overall health
status, nutritional intake (ask specifically about sufficient intake of folic acid and
protein), and lifestyle (especially drinking, smoking, and recreational drug habits);
identify any potential problems (such as a risk for ectopic pregnancy because of tubal
scarring); and identify a woman’s understanding and expectations of conception,
pregnancy, and parenthood.

In early pregnancy, be certain you establish a trusting relationship with a woman

so she will see you as a person who is capable of counseling her and helping her
solve problems and in whom she will be able to confide about any worries she has.
Continue to assess a woman’s health and nutritional status as well as the well-being
of her fetus at all prenatal visits. Physical changes can be learned through health
history, physical assessment, and laboratory tests. An assessment in psychological
areas is obtained primarily through interviewing and should include societal, cultural,
family, and personal influences as a woman adapts to pregnancy.

NURSING DIAGNOSIS
Examples of nursing diagnoses involving the changes that occur with pregnancy
include:
 Altered breathing patterns related to respiratory system changes of pregnancy
 Disturbed body image related to weight gain from pregnancy
 Deficient knowledge related to normal changes of pregnancy
 Imbalanced nutrition, less than body requirements, related to early morning
nausea
 Powerlessness related to unintended pregnancy
 Possible impaired health and prenatal care behaviors associated with cultural
beliefs

OUTCOME IDENTIFICATION AND PLANNING

Planning nursing care in connection with the physiologic and psychological changes
of pregnancy should involve a plan to review the common concerns women have
about being pregnant before changes occur, so there are no surprises. Refer patients
to helpful websites and other resources when appropriate (see Chapter 9).

IMPLEMENTATION
Most women of childbearing age have a mental picture of themselves or a good idea
of how they will look in a dress before they try it on. They participate in sports or
other activities that conform to that self-image. Then, in a span of 9 months, they gain
25 to 30 lb and their figure changes so drastically that their prepregnancy clothes may
no longer fit. At the beginning of a pregnancy, a woman may feel constantly
nauseated; toward the end, the extra weight and the strain of waiting may make her
feel tired and short of breath. Endocrine changes can make her feel moody and quick
to cry.

Help women at prenatal visits to voice their concerns about the changes happening
to them so any worry brought on by these changes does not lead to a stressful 9
months for them or prevent solid bonding with their baby.

OUTCOME EVALUATION
Evaluation should determine whether a woman has really “heard” your teaching.
Remember that people under stress do not always comprehend well, so it is not
unusual for a woman who is worried about her pregnancy to pocket away
information, thinking, “I’ll concentrate on that when it happens to me, not now.”
Then, when a particular change does happen, she realizes she has forgotten what you
said. Examples of outcome criteria you might strive for include:
 Patient states she is able to continue her usual lifestyle throughout pregnancy.
 Family members describe ways they have adjusted their lifestyles to
accommodate the mother’s fatigue.
 Couple states they appreciate the physiologic changes of pregnancy and even
though they are causing discomfort, they know these are healthy changes.

Psychological Changes of Pregnancy

Pregnancy is such a huge change in a woman’s life; it brings about more psychological
changes than any other life event besides puberty (Fletcher & Russo, 2015). How a
woman adjusts to a pregnancy depends a great deal on psychological aspects, such as
the environment in which she was raised, the messages about pregnancy her family
communicated to her as a child, the society and culture in which she lives as an adult,
and whether the pregnancy has come at a good time in her life (Silveira, Ertel, Dole, et
al., 2015).

For many women, a prenatal visit is the first time they have seen a healthcare
provider since childhood. Guidance given during this time can be instrumental in not
only guiding a woman safely through a pregnancy but also connecting her back with
ongoing health care.
SOCIAL INFLUENCES
From the first part of the 20th century until about the 1960s, there was such heavy
emphasis on medical management for women during pregnancy that it conveyed the
idea that pregnancy was a 9-month-long illness. The pregnant woman went alone to a
physician’s office for care; at the time of birth, she was separated from her family,
hospitalized in seclusion from visitors, and even from the new baby for 1 week
afterward so the newborn could be fed by nurses.

Today, pregnancy is viewed as a healthy span of time best shared with a supportive
partner and/or family. Women bring their families for prenatal care visits as well as to
watch the birth. Women choose what level of pain management they want to use for
labor and birth; many women choose to breastfeed their newborn.

How well a pregnant woman and her partner feel during pregnancy and are prepared
to meet the challenges this new responsibility brings is related to their cultural
background, their personal beliefs, the experiences reported by friends and relatives, as
well as by the current plethora of information available on the Internet. Nurses play an
important role in teaching women about their healthcare options as well as continuing
to work with other healthcare providers to “demedicalize” or humanize childbirth
(Heatley, Watson, Gallois, et al., 2015).

CULTURAL INFLUENCES
A woman’s cultural background may strongly influence how active a role she wants to
take in her pregnancy because certain beliefs and taboos can place restrictions on her
behavior and activities (Guelfi, Wang, Dimmock, et al., 2015). To learn about the
beliefs of a particular woman and her partner, ask at prenatal visits if there is anything
the couple believes should or should not be done to make the pregnancy successful and
keep the fetus healthy. Supporting these beliefs shows respect for the individuality of a
woman and her knowledge of good health (Box 10.2)

Nursing Care Planning to Respect Cultural Diversity

Women react differently on realizing they are pregnant based on their individual
circumstances and their cultural expectations.
Women eat different foods during pregnancy based on what they perceive will be
“good” or “bad” for their infant. Assess women’s intake carefully to be certain a
particular woman is not eating nonfood substances such as ice cubes or raw flour, for
instance (called pica), during pregnancy. These habits result from a woman entering
pregnancy with low iron stores so iron-deficient anemia results. Cravings such as ice
cubes are harmless to a fetus, but asking about pica can reveal women eating
substances such as paint chips or sniffing gasoline, which could be harmful to fetal
growth.

Before evidence-based practice was available to scientifically support why

pregnancy brought about changes in a woman’s body, different societies devised
differing explanations about why changes occurred. These myths became so well
engrained in cultures that some persist to the present. For example, a belief that lifting
your arms over your head during pregnancy will cause the cord to twist or that watching
a lunar eclipse will cause a birth deformity are still believed by women in some cultures
(Lauderdale, 2016). Find a compromise that will assure a woman that these are not
really harmful to a fetus but that still respects these beliefs.

FAMILY INFLUENCES
The family in which a woman was raised can be influential to her beliefs about
pregnancy because it is part of her cultural environment. If she and her siblings were
loved and their births were seen as a pleasant outcome of their family, she is more likely
to have a positive attitude toward learning she is pregnant than if she and her siblings
were blamed for the breakup of a marriage or a relationship, for example. A woman
who views mothering as a positive activity is more likely to be pleased when she
becomes pregnant than one who does not value mothering.

INDIVIDUAL DIFFERENCES
A woman’s ability to cope with or adapt to stress plays a major role in how she can
resolve any conflict she feels at becoming a mother. This ability to adapt (e.g., to being
a mother without needing mothering, to loving a child as well as a partner, to becoming
a mother for each new child) depends, in part, on her basic temperament, on whether
she adapts to new situations quickly or slowly, on whether she faces them with intensity
or maintains a low-key approach, and on whether she has had experience coping with
change and stress (Guedes & Canavarro, 2014).

The extent to which a woman feels secure in her relationship with the people around
her, especially the father of her child or her chief support person, is usually also
important to her acceptance of a pregnancy. Anxiety as to whether her partner may
soon disappear, leaving her alone to raise a child, may make her reexamine whether her
pregnancy is a wise life step.

Yet another influence on how women perceive pregnancy as a positive or negative

experience is past experiences (Muzik, McGinnis, Bocknek, et al., 2016). A woman
who thinks of brides as young but mothers as old may believe pregnancy will rob her of
her youth. If she’s concerned about her appearance, she may worry pregnancy will
permanently stretch her abdomen and breasts. She may also worry pregnancy will rob
her financially and ruin her chances of job promotion (referred to as a “mommy track”)
(Misri & Swift, 2015).

These are real feelings and must be taken seriously when assessing or counseling
pregnant women. Women who do not have a supportive partner may look to healthcare
providers during pregnancy to fill the role of an attentive listener (Adeniran, Aboyeji,
Fawole, et al., 2015).

Partner’s Adaptation
The more emotionally attached a partner is to a pregnant woman, the closer the
partner’s attachment is apt to be to the child (Fuertes, Faria, Beeghly, et al., 2016).
Whether partners are able to form a close relationship with each other, as well as
accept a pregnancy and a coming child, depends on the same factors that affect the
pregnant woman’s decision making: cultural background, past experience, and
relationships with family members (Fortinash & Holoday Worret, 2012).
Although partners may be inarticulate about such emotional factors, they may be
able to convey such feelings by a touch or a caress, which is one reason a partner’s
presence is always desirable at a prenatal visit and certainly in a birthing room.

The Psychological Tasks of Pregnancy

During the 9 months of pregnancy, a woman and her partner run a gamut of emotions,
ranging from surprise at finding out about the pregnancy (or wishing she were not), to
pleasure and acceptance as they begin to identify with the coming child at the middle of
pregnancy, to worry for themselves and the child, to acute impatience near the end of
pregnancy (Table 10.1). Once the child is born, a woman and her partner may feel
surprised again that the pregnancy is over and they really do have a child.

From a physiologic standpoint, it is fortunate that a pregnancy is 9 months long

because this gives the fetus time to mature and be prepared for life outside the
protective uterine environment. From a psychological standpoint, the 9-month period is
also fortunate because it gives a family time to prepare emotionally as well. These
psychological changes are frequently termed “guaranteeing safe passage” for the fetus.

Although the average woman is happy to be pregnant, don’t underestimate the effect
the emotional and physical upheavals brought about by the hormonal changes of
pregnancy can cause. These can be so tremendous that they can influence whether a
pregnancy is carried to term, which may not only lead to poor acceptance of the child
but also to postpartum depression or, in rare instances, psychosis (Biaggi, Conroy,
Pawlby, et al., 2016; Lilliecreutz, Larén, Sydsjö, et al., 2016).
FIRST TRIMESTER: ACCEPTING THE PREGNANCY
The Woman
The task of women during the first trimester of pregnancy is to accept the reality of the
pregnancy; later will come the task of accepting the baby. Most cultures structure
celebrations around important life events such as coming of age, marriages, birthdays,
and deaths, all of which have rituals to help individuals face and accept the coming
change in their lives. A diagnosis of pregnancy is a similar rite of passage, but an
unusual one among passages, because the suspicion of pregnancy is made initially not
on something happening but the absence of something: a missed menstrual flow.

With the availability and common use of reproductive planning measures today, it
would seem few pregnancies would still be a surprise. In reality, as many as 49% of
pregnancies are still unintended, unwanted, or mistimed (Centers for Disease Control
and Prevention [CDC], 2015). Because no woman can be absolutely confident in
advance that she will be able to conceive until it happens, even planned pregnancies are
a surprise to some extent because a woman can be amazed it either happened so
quickly or took so long.

How women feel about being pregnant has a great deal to do with how anxious they
are about becoming pregnant. To investigate whether women look forward to a
second birth or whether anxiety about their first birth makes them reluctant to have a
second child, researchers interviewed 908 women who had given birth to at least one
child, asking them to “please describe your feelings when you think about giving
birth in the future.”

Results showed that two thirds of women who responded had mostly positive
feelings; one third of women stated they were frightened of future childbirth. The
qualitative analysis resulted in an overall theme of women feeling a mixture of both
dread and delight at the thought of a second pregnancy (Rilby, Jansson, Lindblom, et
al., 2012).

Following their initial surprise, women often experience feelings less than pleasure
and closer to anxiety or a feeling of ambivalence. Ambivalence doesn’t mean positive
feelings counteract negative feelings and a woman is left feeling nothing. Instead, it
refers to the interwoven feelings of wanting and not wanting, feelings which can be
confusing to an ordinarily organized woman.

Fortunately, most women who were not happy about being pregnant at the
beginning are able to change their attitude toward their pregnancy by the time they feel
the child move inside them. Some healthcare plans provide for a routine sonogram at
about this time in pregnancy, between 18 and 22 weeks, to date the pregnancy and to
assess for growth anomalies. This can be a major step in promoting acceptance because
women can see a beating heart or a fetal outline or can learn the sex of their fetus
(Lindberg, Maddow-Zimet, Kost, et al., 2015).
Although most women self-diagnose their pregnancy by using a urine pregnancy
test strip, hearing their pregnancy officially diagnosed at a first prenatal visit is another
step toward accepting a pregnancy. Because this happens, woman often comment after
such a visit they feel “more pregnant” or it makes a first visit more than an ordinary one.
Early diagnosis is important because the earlier a woman realizes she is pregnant or
comes for a first prenatal visit, the sooner she can begin to safeguard fetal health by
measures such as discontinuing all drugs not specifically prescribed or approved by her
primary healthcare provider (Chakraborty, Anstice, Jacobs, et al., 2015).

The Partner
In the past, partners were forgotten persons in the childbearing process. Unwed fathers
were dismissed as not interested in either the pregnancy or the woman’s health. A
female partner was completely ignored. In actuality, all partners are important and
should be encouraged to play a continuing emotional and supportive role in a
pregnancy.

Accepting the pregnancy for a partner means not only accepting the certainty of the
pregnancy and the reality of the child to come but also accepting the woman in her
changed state. Like women, partners may also experience a feeling of ambivalence. A
partner may feel proud and happy at the beginning of pregnancy, for example. Soon,
however, it’s easy to begin to feel both overwhelmed with what the loss of a salary will
mean to the family if the woman has to quit work, and a feeling close to jealousy of the
growing baby who, although not yet physically apparent, seems to be taking up a great
deal of the woman’s time and thought (Da Costa, Zelkowitz, Dasgupta, et al., 2015).
Remember, once partners feel an attachment to a coming child, they can then feel as
deep a sense of loss as the woman if the pregnancy should end before term or the baby
is born with a unique concern. In addition, they may not have anyone to turn to for
support because no one recognizes how involved they were in the pregnancy. To help
both male and female partners resolve these feelings, be certain to make partners feel
welcome at prenatal visits or during fetal testing, provide an outlet for them to discuss
concerns, and offer parenting information as necessary.

SECOND TRIMESTER: ACCEPTING THE BABY

As soon as fetal movements can be felt, psychological responses of both partners
usually begin to change.

The Woman
During the second trimester, the psychological task of a woman is to accept she is
having a baby, a step up from accepting the pregnancy. This change usually happens at
quickening, or the first moment a woman feels fetal movement. Until a woman
experiences for herself this proof of the child’s existence and although she ate to meet
nutritional needs and took special vitamins to help the fetus grow, it seemed more like
just another part of her body. With quickening, the fetus becomes a separate identity.
She then may imagine herself as a mother, teaching her child the alphabet or how to
ride a bicycle. This anticipatory role-playing is an important activity for midpregnancy as
it leads her to a greater concept of her condition and helps her realize she is more than
just pregnant—there is a separate human being inside her.

Women often use the term “it” to refer to their fetus before quickening but begin to
use he or she afterward. Some women continue to use it, however, so doing so is not a
sign of poor attachment but an individual preference as some women believe referring
to the child as “she” or “he” will bring bad luck or disappointment if the sonogram
report was wrong.

Most women can pinpoint a moment during each pregnancy when they knew
definitely they wanted their child. The firmer this attachment, the less postpartum
depression they are apt to experience (Brummelte & Galea, 2015).

For a woman who carefully planned the pregnancy, this moment of awareness may
occur as soon as she recovers from the surprise of learning she has actually conceived.
For others, it may come when she announces the news to her parents and hears them
express their excitement or when she sees a look of pride on her partner’s face. For
example, shopping for baby clothes for the first time, setting up the crib, or seeing a
blurry outline on a sonogram screen may suddenly make the coming baby seem real and
desired (Fig. 10.1).

Accepting the baby as a welcome addition to the family might not come, however,
until labor has begun or a woman first hears her baby’s cry or feeds her newborn. If a
woman has a complication of pregnancy, it could take several weeks after the baby is
born for her to accept that the birth was real and to come to terms with motherhood.

A good way to measure the level of a woman’s acceptance of her coming baby is to
measure how well she follows prenatal instructions. Until a woman views the growing
life inside her as something desired, it may be difficult for her to substitute a
highprotein
food for her favorite high-calorie coffee drink, for instance. After all, until her
abdomen begins to enlarge, watching herself gain weight may be the most certain proof
she has that she is pregnant.

The Partner
As a woman begins to actively prepare for the coming baby, a partner increasingly may
feel as if he or she is left standing in the wings, waiting to be asked to take part in the
event. To compensate for this feeling, a partner may become overly absorbed in work,
striving to produce something concrete on the job as if to show the woman is not the
only one capable of creating something. This preoccupation with work may limit the
amount of time a partner spends with family or is available for prenatal visits, just when
the pregnant woman most needs emotional support.

Some men may have difficulty enjoying the pregnancy because they have been
misinformed about sexuality, pregnancy, and women’s health. A man might believe, for
example, that breastfeeding will make his wife’s breasts no longer attractive or that
after birth, sexual relations will no longer be enjoyable. Such a man needs education to
correct misinformation. Read the pamphlets supplied by your prenatal healthcare
setting and ask: Do they contain mainly information about childbirth and pregnancy
from a woman’s perspective? Would they be relevant to a supportive partner?

THIRD TRIMESTER: PREPARING FOR PARENTHOOD

During the third trimester, couples usually begin “nest-building” activities, such as
planning the infant’s sleeping arrangements, choosing a name for the infant, and
“ensuring safe passage” by learning about birth. These preparations are evidence the
couple is completing the third trimester task of pregnancy or preparing for parenthood.

Couples at this point are usually interested in attending prenatal classes and/or
classes on preparing for childbirth. It’s helpful to ask a couple what specifically they are
doing to get ready for birth to see if they are interested in taking such a class and to
document how well prepared they will be for the baby’s arrival. Attending a childbirth
education class or one on preparing for parenthood can not only help a couple accept
the fact they are about to become parents but also expose them to other parents as role
models who can provide practical information about pregnancy and child care (Jones,
Feinberg, & Hostetler, 2014). Chapter 14 discusses the usual curriculum of childbirth
and parenthood education classes.

Although pregnancy is a happy time for most women, certain external life
contingencies such as an unwanted pregnancy, financial difficulties, lack of emotional
support, or high levels of stress can slow the psychological work of pregnancy or
attachment to the child (Biaggi et al., 2016) (Box 10.4). During prenatal visits, ask such
questions as “Is pregnancy what you thought it would be?” or “Has anything changed in
your home life since you last came to clinic?” to reveal if any situation that could
potentially interfere with bonding has occurred. It is unrealistic to believe any one
healthcare professional has all the solutions to the problems couples reveal when asked
these questions. An interprofessional approach (referral to a nutritionist, a primary
healthcare provider, or social services) is often necessary to help solve some of these
multifaceted problems.

ADDITIONAL PREPARATION WORK TO COMPLETE IN

PREGNANCY
In addition to the three main tasks of pregnancy, more subtle emotions also surface or
need to be worked through.

Reworking Developmental Tasks

An important task to complete during pregnancy is working through previous life
experiences or Erikson’s developmental tasks of autonomy, industry, and identity
(Erikson, 1993). Needs and wishes that have been repressed for years may surface to be
studied and reworked, often to an extreme extent along these lines.

Fear of being separated from family or fear of dying are common preschool fears
that can be revived during pregnancy. A clue that might signal a woman’s distress over
this could be “Am I ever going to make it through this?” Such an expression might
simply mean she is tired of her backache, but it also might be a plea for reassurance
she will survive this event in her life.

Part of gaining a sense of identity is establishing a working relationship with

parents, which may still be an awkward one since adolescence. For the first time in her
life, a woman during pregnancy can begin to empathize with the way her mother used
to worry because she’s already begun to worry about her child when she feels no
movement for a few hours. This can make her own mother become more important to
her and a new, more equal relationship may develop.

Teenagers who are pregnant need to resolve the double conflict of still establishing a
sense of identity (teenagers are still children developmentally) at the same time they
are planning to be a mother. Unless these feelings are examined and resolved,
teenagers can have a difficult time thinking about enjoying their pregnancy or becoming
a mother.

A partner needs to do the same reworking of old values and forgotten developmental
tasks. A man has to rethink his relationship with his father, for example, to understand
better what kind of father he will be. Some men may have had emotionally distant
fathers and wish to be more emotionally available to their own children. Support from
healthcare providers and exposure to caring role models can be instrumental in helping
a man achieve this goal.

Role-Playing and Fantasizing

Another step in preparing for parenthood is role-playing, or fantasizing about what it
will be like to be a parent. Just as a child learns what to do by following a mother as she
sets a table or balances her checkbook, a pregnant woman may begin to spend time
with other pregnant women or mothers of young children to learn how to be a mother.
As a part of this role-playing process, women’s dreams tend to focus on the pregnancy
and concerns about keeping themselves and their coming child safe.

There is concern that a young adolescent will have inadequate role models for
motherhood; they are either other teens her age, who typically are not interested in a
commitment to mothering, or possibly her own mother, who may have struggled with
poverty or her own lack of support. Try to locate good role models (e.g., in classes for
mothers, at the healthcare agency, or in a social agency) for adolescents so they can find
a good maternal role model to copy and modify their own behavior.

A woman’s partner also has the same role-playing to do during pregnancy, to

imagine himself or herself as the parent of a boy or a girl. A partner who is becoming a
parent for the first time may have to change a view of being a carefree individual to
being a significant member of a family unit. If the partner already is a parent from a
former relationship, he or she has to cast aside the parent-of-one identity to accept a
parent-of-two image, and so forth.

Other support persons who will have an active role in raising the child, such as
grandparents, close friends, or an ex-spouse, also have to work out their roles with
regard to the pregnancy and impending parenthood. This may be particularly difficult
because the roles for these support persons may not be clearly defined, and no role
model may be apparent (Hayslip, Blumenthal, & Garner, 2015).

EMOTIONAL RESPONSES THAT CAN CAUSE CONCERN IN

PREGNANCY
Because of all the tasks that need to be worked through during a pregnancy, emotional
responses can vary greatly, but common reactions include grief, narcissism, introversion
or extroversion, body image and boundary concerns, couvade syndrome, stress, mood
swings, and changes in sexual desire. These are all normal, so it is helpful to caution a
pregnant woman and her partner that these common changes may occur so they’re not
alarmed if they appear. Otherwise, a partner can misinterpret the woman’s mood
swings, decreased sexual interest, introversion, or narcissism not as changes from
pregnancy but as a loss of interest in their relationship.

Grief
The thought that grief can be associated with such a positive process as having a child
seems at first incongruent. But before a woman can take on a mothering role, she has to
give up or alter her present role as she will never be the woman she has been in exactly
the same way again. She will never be able to be as irresponsible and carefree again, or
perhaps sleep soundly for the next few years. All of this takes mental preparation, which
may manifest as a form of grief, as she incorporates her new role as a mother into her
other roles as daughter, wife, business professional, or friend. Partners must also
incorporate a new role as a parent into their other roles in life.

Narcissism
Self-centeredness (narcissism) may be an early reaction to pregnancy. A woman who
previously perhaps was barely conscious of her body, who dressed in the morning with
little thought about what to wear, suddenly begins to concentrate on these aspects of
her life. She dresses so her pregnancy will or will not show. She may lose interest in her
job or community events because the work seems alien to the more important event
taking place inside her.

Narcissism may also be revealed by changes in activity. A woman may stop playing
tennis, for example, even though her primary healthcare provider has assured her it will
do no harm in moderation. She may criticize her partner’s driving, although it never
bothered her before. She does these things to unconsciously protect her body and her
baby. Her partner may demonstrate the same behavior by reducing risky activities, such
as mountain biking, trying to ensure he or she will be present to raise their child.

This need of a woman to protect her body has implications for nursing care. It
means a woman may regard unnecessary nudity as a threat to her body (e.g., be sure to
drape properly for pelvic and abdominal examinations). She may resent casual remarks
such as “Oh my, you’ve gained weight” (i.e., a threat to her appearance) or “You don’t
like milk?” (i.e., a threat to her judgment).

There is a tendency to organize health instructions during pregnancy around the

baby: “Be sure to keep this appointment. You want to have a healthy baby.” “You really
ought to eat more protein for the baby’s sake.” This approach may be particularly
inappropriate early in pregnancy, before the fetus stirs and before a woman is
convinced not only that she is pregnant but also that there is a baby inside her. At early
stages, a woman may be much more interested in doing things for herself because it is
her body, her tiredness, and her well-being that will be directly affected (e.g., “Eat
protein because it keeps your fingernails from breaking” or “Protein will give you long-
term energy”).

Introversion Versus Extroversion

Introversion, or turning inward to concentrate on oneself and one’s body, is a common
finding during pregnancy. Some women, however, react in an entirely opposite fashion
and become more extroverted. They are more active, appear healthier than ever before,
and are more outgoing. This tends to occur in women who are finding unexpected
fulfillment in pregnancy, perhaps who had seriously doubted they would be lucky
enough or fertile enough to conceive. Such a woman regards her expanding abdomen as
public proof of her ability to fulfill the maternal role. Although these changes may make
a woman become more varied in her interests during pregnancy, she may be puzzling to
those around her who liked her for her quiet and self-contained manner.

Body Image and Boundary

Body image (i.e., the way your body appears to yourself) and body boundary (i.e., a
zone of separation you perceive between yourself and objects or other people) both
change during pregnancy as a woman begins to envision herself as a mother or
becoming “bigger” in many different ways. Changes in concept of body boundaries are
so startling that a pregnant woman may walk far away from an object such as a table to
avoid bumping against it. At the same time, she may perceive herself as needing body
boundaries as if her body were delicate and easily harmed.

Stress
Because pregnancy brings with it such a major role change, it can cause extreme stress
in a woman who was not planning to be pregnant or if she finds her lifestyle changing
dramatically after she becomes pregnant. Stress in pregnancy, like stress at any time,
can make it difficult for a woman to make decisions, be as aware of her surroundings as
usual, or maintain time management with her usual degree of skill. This may cause
people who were dependent on her before pregnancy to feel neglected because now
that she is pregnant, she seems to have strength only for herself. If a woman was in a
violent relationship before the pregnancy, the increased stress of pregnancy is apt to
cause even more violence. Privately asking whether intimate partner violence has ever
occurred in the past to help predict if it could occur during pregnancy is an important
part of prenatal interviewing (Van Parys, Deschepper, Michielsen, et al., 2015).

To help families keep their perspective for the full length of a pregnancy, remind
them that any decrease in the ability to function that happens to a pregnant woman is a
reaction to the stress of pregnancy. A woman may need to remind an employer that any
lack of decision-making ability is no different than in people who are feeling stress
because of marital discord or a loved one’s illness. Pregnancy may actually be less
stressful and less of a concern than those situations because of its predictable 9-month
duration.
Depression
Depression—a feeling of sadness marked by loss of interest in usual things, feelings of
guilt or low self-worth, disturbed sleep, low energy, and poor concentration—is a
common finding in late adolescents. Depression causes as many as 15% of women to
enter pregnancy feeling depressed; others grow depressed during pregnancy, especially
if they lack a meaningful support person (Chojenta, Lucke, Forder, et al., 2016).
Screening for women who have a history of depression is important at a preconception
visit as common drugs prescribed for depression can be teratogenic to a fetus as well as
cause hypertension in the woman (Zoega, Kieler, Nørgaard, et al., 2015). It is also
important to investigate if the woman has a meaningful support person or the stress
and anxiety that can come with pregnancy can increase depression substantially and
lead to postpartum depression.

A woman with few support people around her almost automatically has more
difficulty adjusting to and accepting a pregnancy and a new child than women with
more support. A woman who begins a pregnancy with a strong support person and then
loses that person through trauma, illness, separation, or divorce needs special attention
with regard to loneliness and depression. Evaluate her carefully as to how she is
managing and give her extra support as needed because her feeling of loss is likely to be
extremely acute. Knowing she has supportive healthcare providers she can call on when
needed is the one thing that may make her pregnancy acceptable to her.

Couvade Syndrome
Many partners experience physical symptoms such as nausea, vomiting, and backache
to the same degree or even more intensely than their partners during a pregnancy;
some begin to gain weight along with their partner. As a woman’s abdomen begins to
grow, partners may perceive themselves as growing larger too, as if they were the ones
who were experiencing changing boundaries the same as the pregnant woman. These
symptoms apparently result from stress, anxiety, and empathy for the pregnant woman.
The phenomenon is common enough that it has been given a name: couvade syndrome
(from the French word “to hatch”). The more a partner is involved in or attuned to the
changes of the pregnancy, the more symptoms a partner may experience. A close
marital relationship, which this reflects, can increase the strength of the partner–infant
attachment (Fuertes et al., 2016). Such symptoms are only worrisome and require
psychological attention if they become so extreme that they create intolerable
emotional stress.

Emotional Lability
Mood changes occur frequently in a pregnant woman, partly as a symptom of
narcissism (i.e., her feelings are easily hurt by remarks that would have been laughed
off before) and partly because of hormonal changes, particularly the sustained increase
in estrogen and progesterone. Mood swings may be so common that they can make a
woman’s reaction to her family and to healthcare routines unpredictable. She may cry
over her children’s bad table manners at one meal, for example, and find the situation
amusing or even charming at the next. Caution families that such mood swings occur
beginning with early pregnancy so they can accept them as part of a normal pregnancy.

Nursing Care Planning Based on Family Teaching(Mood Swing)

Everyone is different, but good measures to try include:
• Avoid fatigue because when you’re tired, your normal defenses are most likely to
be down.
• Reduce your level of stress by setting priorities. Ask yourself if everything you’re
doing really needs to be done.
• Don’t let little problems grow into big ones; attack them when they first occur.
• Try to view situations from other people’s perspective. They’re not as involved in
your pregnancy as you are so things that don’t seem important to you may be
important to them.
• Let others know you’re aware you’re having trouble with emotions since you
became pregnant. Your family and friends will be more than willing to help you
through this time if they realize your shifting emotions are a concern to you.

Changes in Sexual Desire

Most women report their sexual desire changes, at least to some degree, during
pregnancy. Women who formerly were worried about becoming pregnant might truly
enjoy sexual relations for the first time during pregnancy. Others might feel a loss of
desire because of their increase in estrogen, or they might unconsciously view sexual
relations as a threat to the fetus they must protect. Some may worry coitus could bring
on early labor.

During the first trimester, most women report a decrease in libido because of the
nausea, fatigue, and breast tenderness that accompany early pregnancy. During the
second trimester, as blood flow to the pelvic area increases to supply the placenta,
libido and sexual enjoyment can rise markedly. During the third trimester, sexual desire
may remain high, or it may decrease because of difficulty finding a comfortable position
and increasing abdominal size. When a couple knows early in pregnancy such changes
may occur, it’s easier for them to interpret these in the correct light or as a normal
change, not as loss of interest in a sexual partner or as a diminishment of the strength of
the total relationship (Yıldız, 2015). Suggestions for helping women and their partners
adjust to these circumstances are discussed in Chapter 12.

Changes in the Expectant Family

Most parents are aware that their older children need preparation when a new baby is
on the way; however, knowing preparation is needed and being prepared to explain
where babies come from are two different things. For this reason, many couples
appreciate suggestions from healthcare providers as to how this task can be
accomplished.

Both preschool and school-age children may need to be assured periodically during
pregnancy a new baby will be an addition to the family and will not replace them or
change their parents’ affection for them. Preparing a child for the birth of a sibling is
discussed in Chapters 14 and 31 with other growth and development concerns.

The Confirmation of Pregnancy

A medical diagnosis of pregnancy serves to date when the birth will occur and also
helps predict the existence of a high-risk status. Most women who come to a healthcare
facility for a diagnosis of pregnancy have already guessed they are pregnant based on a
multitude of subjective symptoms as well as having completed a home pregnancy test,
so a healthcare visit is more a confirmation of pregnancy than a diagnosis. If a
pregnancy was planned, this official confirmation of pregnancy produces a feeling of
intense fulfillment and achievement. If the pregnancy was not planned (remember
almost half of pregnancies are unintended), it can result in an equally extreme crisis
state.

From the day a pregnancy is officially confirmed, most women try to eat a more
nutritious diet, give up cigarette smoking and alcohol ingestion, and stop taking
nonessential medications. Because a woman may not take these measures before
confirmation of her pregnancy, this makes early confirmation of pregnancy important. If
a woman does not wish to continue the pregnancy, early confirmation is also
imperative; therapeutic termination of pregnancy should be carried out at the earliest
stage possible for the safest outcome (Gerdts, Dobkin, Foster, et al., 2016).

Before there were sonograms and maternal serum pregnancy tests, pregnancy was
diagnosed on symptoms reported by the woman and the signs elicited by a healthcare
provider. These signs and symptoms, still important today, are traditionally divided into
three classifications: presumptive (subjective symptoms), probable (objective signs),
and positive (documented signs).

PRESUMPTIVE (SUBJECTIVE) SYMPTOMS

Presumptive symptoms are those which, when taken as single entities, could easily
indicate other conditions (Fletcher & Russo, 2015). These findings, discussed in
connection with the body system in which they occur, are experienced by the woman
but cannot be documented by an examiner.
PROBABLE SIGNS
In contrast to presumptive symptoms, probable signs of pregnancy are objective and so
can be verified by an examiner. Although they are more reliable than presumptive
symptoms, they still do not positively diagnosis a pregnancy.

Laboratory Tests
The commonly used laboratory tests for pregnancy are based on the use of a
venipuncture or a urine specimen to detect the presence of human chorionic
gonadotropin (hCG), a hormone created by the chorionic villi of the placenta, in the
urine or blood serum of the pregnant woman. Because these tests are only accurate
95% to 98% of the time, positive results from these tests are considered probable rather
than positive signs.

In the nonpregnant woman, no units of hCG will be detectable because there are no
trophoblast cells producing hCG. In the pregnant woman, trace amounts of hCG appear
in her serum as early as 24 to 48 hours after implantation and reach a measurable level
(about 50 milli-International Unit/ml 7 to 9 days after conception. Levels peak at about
100 milli-International Unit/ml between the 60th and 80th day of gestation. After that
point, the concentration of hCG declines again so, at term, it is again barely detectable
in serum or urine.

Home Pregnancy Tests

A number of brands for pregnancy testing are available over the counter, take only 2 to
3 minutes to complete, and have a high degree of accuracy (97% to 99%) if the
instructions are followed exactly because they can detect as little as 35 milli-
International Unit/ml of hCG. For the test, a woman dips a reagent strip into her stream
of urine. A color change or the appearance of two bars on the strip denotes pregnancy.
Tips to give the woman for successful testing include:
• Check the expiration date on the package to be certain the kit has not expired; an
outdated kit can give false-positive results.
• Read the instruction pamphlet provided with the test, noting especially the time
period you should wait before reading the result, and follow this instruction
carefully.
• A concentrated urine sample such as a first urine in the morning tests best. Don’t
drink a large quantity of water beforehand because this can dilute a urine sample.
• Read the test results at the exact time the instructions dictate. Reading the strip
after the designated time can cause inaccurate results (e.g., denoting that you are
pregnant when you are not).
• Some prescription medicines, like methadone or chlordiazepoxide, may cause
false-positive results. Contact your healthcare provider if you get an unexpected
positive result and ask if any medication you are taking could cause that result.
• Early prenatal care is the best safeguard to ensure a successful pregnancy. If your
test result is positive, your next step should be to make a healthcare appointment
as early as possible to begin care.

Most manufacturers suggest a woman wait until at least the day of the missed
menstrual period to test. If a woman thinks she is pregnant but gets a negative result,
she could repeat the test 1 week later if she still has not had a menstrual flow. If
symptoms of pregnancy persist after two tests, she needs to see her healthcare provider
as she might have another condition causing the amenorrhea; she would need
appropriate diagnosis and therapy for this.

A worry about the common use of home test kits is that because women do not have
to come to a healthcare setting for confirmation of pregnancy, they may not seek
prenatal care until something seems to be going wrong with their pregnancy or until
they feel they need to arrange added healthcare provider coverage for the birth. After a
positive pregnancy test, the first step should therefore be to arrange for prenatal care
(Attilakos & Overton, 2012).

POSITIVE SIGNS OF PREGNANCY

There are only three documented or positive signs of pregnancy:
1. Demonstration of a fetal heart separate from the mother’s
2. Fetal movements felt by an examiner
3. Visualization of the fetus by ultrasound

Demonstration of a Fetal Heart Separate From the Mother’s

Although a fetal heart beat cannot be heard through an ordinary stethoscope until 18 to
20 weeks of pregnancy, an echocardiography can demonstrate a heartbeat as early as 5
weeks. An ultrasound can reveal a beating fetal heart as early as the sixth to seventh
week of pregnancy. Doppler instrumentation that converts ultrasonic frequencies to
audible frequencies is able to detect fetal heart sounds as early as the 10th to 12th
week of gestation.

The fetal heart rate ranges between 120 and 160 beats/min. Sounds are more
difficult to hear if a woman’s abdomen has a great deal of subcutaneous fat or if there is
a larger-than-normal amount of amniotic fluid present (polyhydramnios). They are
heard best when the position of the fetus is determined by palpation and the
stethoscope is placed over the area of the fetal back.

Fetal Movements Felt by an Examiner

Fetal movements may be felt by a woman as early as 16 to 20 weeks of pregnancy. An
objective examiner can discern fetal movements at about the 20th to 24th week of
pregnancy unless the woman is extremely obese. This outside evaluation is considered
the more reliable assessment because a woman could mistake the movement of gas
through her intestines for fetal movement.

Visualization of the Fetus by Ultrasound

Ultrasound is the most common method for confirmation of pregnancy today. If a
woman is pregnant, a characteristic ring, indicating the gestational sac, will be revealed
on an oscilloscope screen as early as the fourth to sixth week of pregnancy. This method
also gives information about the site of implantation and whether a multiple pregnancy
exists. By the eighth week, a fetal outline can be seen so clearly that the crown-to-rump
length can be measured to establish the gestational age of the pregnancy. Seeing the
fetal outline on a sonogram is also clear proof for a couple that they are pregnant if they
had any doubt up to that point (Zheng, 2012b).

Note: Although probable signs of pregnancy (such as laboratory tests, ballottement, and
softening of the cervix) are objective and can be verified by an examiner, they are not
reliable enough to positively diagnosis a pregnancy. The only three positive signs of
pregnancy are demonstration of a fetal heartbeat separate from the mother’s, fetal
movement felt by an examiner, and visualization of the fetus by ultrasound.

Physiologic Changes of Pregnancy

Physiologic changes that occur during pregnancy are the basis for the signs and
symptoms used to confirm a pregnancy. They can be categorized as local (i.e., confined
to the reproductive organs) or systemic (i.e., affecting the entire body). For easy
reference, Table 10.3 summarizes the changes that occur during a typical 40-week
pregnancy.

REPRODUCTIVE SYSTEM CHANGES

Reproductive tract changes are those involving the uterus, ovaries, vagina, and breasts.

Uterine Changes
The most obvious alteration in a woman’s body during pregnancy is the increase in size
of the uterus to accommodate the growing fetus. Over the 10 lunar months of
pregnancy, the uterus increases in length, depth, width, weight, wall thickness, and
volume.
• Length grows from approximately 6.5 cm to 32 cm.
• Depth increases from 2.5 cm to 22 cm.
• Width expands from 4 cm to 24 cm.
• Weight increases from 50 g to 1,000 g.
• Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm;
toward the end of pregnancy, the wall thins to become supple and only about 0.5-
cm thick.
• The volume of the uterus increases from about 2 ml to more than 1,000 ml. This
makes it possible for a uterus to hold a 7-lb (3,175-g) fetus plus 1,000 ml of
amniotic fluid for a total of about 4,000 g.

This great uterine growth is due partly to formation of a few new muscle fibers in
the uterine myometrium but principally to the stretching of existing muscle fibers (by
the end of pregnancy, muscle fibers in the uterus because of fibroblastic tissue that
forms between them, are two to seven times longer than they were before pregnancy).
Because uterine fibers simply stretch during pregnancy and are not newly built, the
uterus is able to return to its prepregnant state at the end of the pregnancy with little
difficulty and almost no destruction of tissue (Edmonds, 2012).

By the end of the 12th week of pregnancy, the uterus is large enough that it can be
palpated as a firm globe under the abdominal wall, just above the symphysis pubis. An
important factor to assess regarding uterine growth at healthcare visits is its constant,
steady, and predictable increase in size (Fig. 10.2).
• By the 20th or 22nd week of pregnancy, it typically reaches the level of the
umbilicus.
• By the 36th week, it usually touches the xiphoid process and can make breathing
difficult.
• About 2 weeks before term (the 38th week) for a primigravida, a woman in her
first pregnancy, the fetal head settles into the pelvis and the uterus returns to the
height it was at 36 weeks.

This settling of the fetus into the midpelvis is termed lightening because a woman’s
breathing is so much easier that she feels as if her load is lightened. The point at which
lightening will occur is not predictable in a multipara (a woman who has had one or
more children). In such women, it may not occur until labor begins.

Uterine height is measured from the top of the symphysis pubis to over the top of
the uterine fundus (Zheng, 2012a). Although growth of a uterus implies a pregnancy is
causing the increase in size because a uterine tumor could also cause uterine growth,
uterine growth is only a presumptive symptom of pregnancy.

The exact shape of the expanding uterus can be influenced by the position of the
fetus. As the uterus grows larger, it pushes the intestines to the sides of the abdomen,
elevates the diaphragm and liver, compresses the stomach, and puts pressure on the
bladder. It usually remains in the midline during pregnancy, although it may be pushed
slightly to the right side because of the larger bulk of the sigmoid colon on the left. A
woman may worry there will not be enough room inside her abdomen for this much
increase in size. You can assure her the abdominal contents will readily shift to
accommodate uterine enlargement (Fig. 10.3).

Uterine blood flow increases during pregnancy as the placenta requires more and
more blood for perfusion. Doppler ultrasonography has shown that, before pregnancy,
uterine blood flow is 15 to 20 ml/min. By the end of pregnancy, it expands to as much
as 500 to 750 ml/min, with 75% of that volume going to the placenta. Measuring an
increase in placenta blood volume and velocity is an important gauge of fetal health
(Khong, Kane, Brennecke, et al., 2015).

Circulation to the uterus increases so much that toward the end of pregnancy, one
sixth of a woman’s blood supply is circulating through the uterus at any given time; this
means uterine bleeding in pregnancy has to always be regarded as serious because it
could result in sudden and major blood loss. Caution women to contact their healthcare
provider if any vaginal bleeding occurs during pregnancy.

A bimanual examination (two fingers of an examiner are placed in the vagina, the
other hand on the abdomen) can demonstrate, during a pregnancy, that the uterus feels
more anteflexed, larger, and softer to the touch than usual. At about the sixth week of
pregnancy (at the time of the second missed menstrual flow), the lower uterine
segment just above the cervix becomes so soft when it is compressed between
examining fingers on bimanual examination that the wall feels as thin as tissue paper
(Fletcher & Russo, 2015). This extreme softening of the lower uterine segment is known
as Hegar’s sign (Fig. 10.4).
During the 16th to 20th week of pregnancy, when the fetus is still small in relation
to the amount of amniotic fluid present, if the lower uterine segment is tapped sharply
during a pelvic exam, the fetus can be felt to bounce or rise in the amniotic fluid up
against a hand placed on the abdomen. This phenomenon, termed ballottement (from
the French word ballotter, meaning “to quake”), may, however, also be simulated by a
loosely attached uterine tumor and, therefore, is no more than a probable sign of
pregnancy.

Between the 20th and 24th week of pregnancy, the uterine wall becomes thinned to
such a degree a fetal outline within the uterus may be palpated by a skilled examiner.
Because a tumor with calcium deposits could simulate a fetal outline, palpation of what
seems to be a fetus, like other uterine assessments, does not constitute a sure
confirmation of pregnancy.

Uterine contractions begin early in pregnancy, at least by the 12th week, and are
present throughout the rest of pregnancy, becoming stronger and harder as the
pregnancy advances. A woman experiences them as waves of hardness or tightening
across her abdomen. If a hand is placed on her abdomen, an examiner may be able to
feel these contractions as well; an electronic monitor can easily measure both the
frequency and length of such contractions.

These “practice” contractions, termed Braxton Hicks contractions, serve as warmup

exercises for labor and also play a role in ensuring the placenta receives adequate
blood. They may become so strong in the last month of pregnancy that a woman
mistakes them for labor contractions (i.e., false labor). One way they can be
differentiated from true contractions is that true contractions cause cervical dilation,
and Braxton Hicks contractions do not (Attilakos & Overton, 2012). Although these
contractions are always present with pregnancy, they also could accompany any
growing uterine mass; so, like ballottement, they are no more than a probable sign of
pregnancy.
Amenorrhea
Amenorrhea (i.e., an absence of a menstrual flow) occurs with pregnancy because of the
suppression of follicle-stimulating hormone (FSH) by rising estrogen levels. In a
healthy woman who has menstruated previously, the absence of a menstrual flow
strongly suggests impregnation has occurred. Amenorrhea, however, also heralds the
onset of menopause or could result from unrelated reasons such as uterine infection,
anxiety (perhaps over becoming pregnant), a chronic illness such as severe anemia,
hormonal imbalance, or undue stress. It also is seen in athletes who train strenuously,
especially in long-distance runners and ballet dancers if their body fat percentage drops
below a critical point (Mountjoy, Sundgot-Borgen, Burke, et al., 2014). Amenorrhea is,
therefore, only a presumptive symptom of pregnancy.

Cervical Changes
In response to the increased level of circulating estrogen produced by the placenta
during pregnancy, the cervix of the uterus becomes more vascular and edematous than
usual. A mucus plug, called the operculum, forms to seal out bacteria and help prevent
infection in the fetus and membranes. Increased fluid between cells causes it to soften
in consistency, and increased vascularity causes it to darken from a pale pink to a violet
hue (Goodell’s sign).

The consistency of a nonpregnant cervix can be compared with that of the nose; the
consistency of a pregnant cervix more closely resembles an earlobe. Just before labor,
the cervix becomes so soft it takes on the consistency of butter or is said to be “ripe” for
birth (Wu & Chou, 2015).

Vaginal Changes
Under the influence of estrogen, the vaginal epithelium and underlying tissues increase
in size as they become enriched with glycogen. Muscle fibers loosen from their
connective tissue base in preparation for great distention at birth. This increase in the
activity of the epithelial cells results in a slight white vaginal discharge throughout
pregnancy (but this is only a presumptive symptom as vaginal infections also produce
discharges).

An increase in the vascularity of the vagina parallels the vascular changes in the
uterus. The resulting increase in circulation changes the color of the vaginal walls from
their normal light pink to a deep violet (Chadwick’s sign).

Vaginal secretions before pregnancy have a pH value greater than 7 (an alkaline
pH). During pregnancy, the pH level falls to 4 or 5 (an acid pH), which helps make the
vagina resistant to bacterial invasion for the length of the pregnancy. This occurs
because of the action of Lactobacillus acidophilus, a bacteria that grows freely in the
increased glycogen environment, which increases the lactic acid content of secretions.
Ovarian Changes
Ovulation stops with pregnancy because of the active feedback mechanism of estrogen
and progesterone produced early in pregnancy by the corpus luteum and late in
pregnancy by the placenta. This feedback causes the pituitary gland to halt production
of FSH and luteinizing hormone (LH); without stimulation from FSH and LH, ovulation
does not occur.

The corpus luteum that was created after ovulation continues to increase in size on
the surface of the ovary until about the 16th week of pregnancy, by which time the
placenta takes over as the chief provider of progesterone and estrogen. The corpus
luteum, no longer essential for the continuation of the pregnancy, regresses in size and
appears white and fibrous on the surface of the ovary (a corpus albicans).

CHANGES IN THE BREASTS

Subtle changes in the breasts may be one of the first physiologic changes of pregnancy a
woman notices (at about 6 weeks) (Fig. 10.5). Typical changes are a feeling of fullness,
tingling, or tenderness that occurs because of the increased stimulation of breast tissue
by the high estrogen level in her body. As the pregnancy progresses, breast size
increases because of growth in the mammary alveoli and in fat deposits. The areola of
the nipple darkens, and its diameter increases from about 3.5 cm (1.5 in.) to 5 cm or 7.5
cm (2 or 3 in.). There is additional darkening of the skin surrounding the areola in some
women, forming a secondary areola.

Early in pregnancy, the breasts begin readying themselves for the secretion of milk.
By the 16th week, colostrum—the thin, watery, high-protein fluid that is the precursor
of breast milk—can be expelled from the nipples. As vascularity of the breasts
increases, blue veins may become prominent over the surface of the breasts. The
sebaceous glands of the areola (Montgomery’s tubercles), which keep the nipple
supple and help to prevent nipples from cracking and drying during lactation, enlarge
and become protuberant.

Talking to women during pregnancy about breast changes and how these changes
are devised to aid breastfeeding can be the trigger that alerts women to the importance
of breastfeeding for their baby (Pratts & Lawson, 2015).

SYSTEMIC CHANGES
Although the physiologic changes first noticed by a woman are apt to be those of the
reproductive system, changes also occur in almost all body systems.

Endocrine System
Almost all aspects of the endocrine system increase during pregnancy in order to
support fetal growth (Table 10.4) (Burton & Jauniaux, 2015).

Immune System
Immunologic competency during pregnancy decreases, probably to prevent a woman’s
body from rejecting the fetus as if it were a transplanted organ. Immunoglobulin G
(IgG) production is particularly decreased, which can make a woman more prone to
infection during pregnancy. A simultaneous increase in the white blood cell count may
help to counteract this decrease in the IgG response.

Integumentary System
As the uterus increases in size, the abdominal wall must stretch to accommodate it. This
stretching (plus possibly increased adrenal cortex activity) can cause rupture and
atrophy of small segments of the connective layer of the skin, leading to streaks (striae
gravidarum) on the sides of the abdominal wall and sometimes on the thighs (Fig.
10.6). During the months after birth, striae gravidarum lighten to a silvery color (striae
albicantes or atrophicae), and, although permanent, they become barely noticeable.
Often, the abdominal wall has difficulty stretching enough to accommodate the
growing fetus, causing the rectus muscles underneath the skin to actually separate, a
condition known as diastasis. If this happens, after pregnancy, the separation can be
assessed through physical exam, and physical therapy can be offered for persistent
diastasis.

The umbilicus is stretched by pregnancy to such an extent that by the 28th week, its
depression becomes obliterated and it is pushed so far outward in some women, it
appears as if it has turned inside out, protruding as a round bump at the center of the
abdominal wall.

Extra pigmentation generally appears on the abdominal wall because of melanocyte-

stimulating hormone from the pituitary. A narrow, brown line (linea nigra) may form,
running from the umbilicus to the symphysis pubis and separating the abdomen into
right and left halves (see Fig. 10.6). Darkened or reddened areas may appear on the face
as well, particularly on the cheeks and across the nose. This is known as melasma
(chloasma) or the “mask of pregnancy.” With the decrease in the level of melanocyte-
stimulating hormone after pregnancy, these areas lighten but do not always disappear.

Vascular spiders or telangiectasias (small, fiery-red branching spots) sometimes

develop on the skin, particularly on the thighs. Palmar erythema, as mentioned earlier,
may occur on the hands. Both of these symptoms result from the increased level of
estrogen in the body; telangiectasias may fade but not completely disappear after
pregnancy. The activity of sweat glands increases throughout the body beginning early
in pregnancy, leading to increased perspiration. Fewer hairs on the head enter a resting
phase because of overall increased metabolism, so scalp hair growth is increased.

Respiratory System
A local change that often occurs in the respiratory system is marked congestion, or
“stuffiness,” of the nasopharynx, a response, again, to increased estrogen levels.
Women may worry this stuffiness indicates an allergy or a cold. Not realizing it is a
symptom of pregnancy, some women take over-the-counter cold medications or
antihistamines in an effort to relieve the congestion. Ask women at prenatal visits if they
are taking any kind of medicine for this to detect this possibility and to be certain the
medication they are taking is safe during pregnancy.

Because the uterus enlarges so much during pregnancy, the diaphragm, and
ultimately, the lungs, receive an increasing amount of pressure. Toward the end of
pregnancy, this can actually displace the diaphragm by as much as 4 cm upward. Even
with all this crowding, however, a woman’s vital capacity (the maximum volume
exhaled after a maximum inspiration) does not decrease during pregnancy because,
although the lungs are crowded in the vertical dimension, they can still expand
horizontally. Two major changes do occur with pregnancy: a more rapid than usual
breathing rate (18 to 20 breaths/min) and a chronic feeling of shortness of breath
(Pipkin, 2012).

The physiologic reasons for those changes include:

• Residual volume (the amount of air remaining in the lungs after expiration) is
decreased up to 20% because of the pressure of the diaphragm.
• Tidal volume (the volume of air inspired) is increased up to 40% as a woman
draws in deeper breaths trying to increase the effectiveness of her air exchange.
• Total oxygen consumption increases by as much as 20%.
• The increased level of progesterone appears to set a new level in the
hypothalamus for acceptable serum carbon dioxide levels (PCO2) because, during
pregnancy, a woman’s body tends to maintain a PCO2 at closer to 32 mmHg than
the usual 40 mmHg. This low PCO2 level is helpful as it causes a favorable CO2
gradient at the placenta (i.e., because the fetal CO2 level is higher than that in the
mother, CO2 crosses readily from the fetus to the mother).
• To keep the mother’s pH level from becoming acidic because of the load of CO2
being shifted to her from the fetus, increased expiration (mild hyperventilation)
to blow off excess CO2 begins early in pregnancy.
• At full term, a woman’s total ventilation capacity may have risen by as much as
40%. This increased ventilation may become so extreme toward the end of
pregnancy that a woman develops a respiratory alkalosis or exhales more than the
usual amount of CO2. To compensate, kidneys excrete plasma bicarbonate in
urine to lower this pH. This results in increased urination or polyuria, a sign of
pregnancy.
• The slight increase in pH in serum because of the changed expiratory effort is
advantageous because it slightly increases the binding capacity of maternal
hemoglobin and thereby raises the oxygen content of maternal blood (PO2), from
a usual level of about 92 mmHg to about 106 mmHg. This can be advantageous
to fetal growth because it helps ensure good oxygenation of the fetus.
• The total respiratory changes and the compensating mechanisms that occur in the
respiratory system can be described as a chronic respiratory alkalosis fully
compensated by a chronic metabolic acidosis (Cunningham, Leveno, Bloom, et
al., 2014).
Changes in respiratory function during pregnancy are summarized in Table 10.5.

Temperature
Early in pregnancy, body temperature increases slightly because of the secretion of
progesterone from the corpus luteum (the temperature, which increased at ovulation,
remains elevated). As the placenta takes over the function of the corpus luteum at
about
16 weeks, the temperature usually decreases to normal.

Cardiovascular System
Changes in the circulatory system are extremely significant to the health of a fetus
because they determine whether there will be adequate placental and fetal circulation
for oxygenation and nutrition. Table 10.6 summarizes these changes.
Gastrointestinal System
At least 50% of women experience some nausea and vomiting early on in pregnancy.
For many women, this is the first sensation a woman experiences with pregnancy (it can
be noticed even before the first missed menstrual period). It is most apparent early in
the morning, on rising, or if a woman becomes fatigued during the day.

Known as morning sickness, nausea and vomiting begins to be noticed at the same
time levels of hCG and progesterone begin to rise, so these may contribute to its cause.
Another reason may be a systemic reaction to increased estrogen levels or decreased
glucose levels because glucose is being used in such great quantities by the growing
fetus. Nausea usually subsides after the first 3 months, after which time a woman may
have a voracious appetite (Festin, 2015). Many alternate or complementary methods to
help reduce nausea are available, such as acupuncture or wrist bands.

In addition to nausea, other gastrointestinal tract changes occur:

• Although the acidity of stomach secretions decreases during pregnancy,
heartburn can readily result from reflux of stomach contents into the esophagus,
caused by both the upward displacement of the stomach by the uterus, and a
relaxed cardioesophageal sphincter, caused by the action of relaxin produced by
the ovary.
• As the uterus increases in size, it pushes the stomach and intestines toward the
back and sides of the abdomen. At about the midpoint of pregnancy, this pressure
may be sufficient to slow intestinal peristalsis and the emptying time of the
stomach, leading to renewed heartburn, constipation, and flatulence.
• Pressure from the uterus on veins returning from the lower extremities can lead
to hemorrhoids.
• The entire gastrointestinal tract may become less active from the combined
actions of relaxin and progesterone. This natural slowing of the stomach and
intestine can be helpful because the blood supply is reduced in the
gastrointestinal tract as more blood is drawn to the uterus.
• Women with chronic gastric reflux usually find their condition either improved
because the acidity of the stomach is decreased or worsened because of upward
uterine pressure.
• Because of the gradual slowing of the gastrointestinal tract, decreased emptying
of bile from the gallbladder may result. This can lead to reabsorption of bilirubin
into the maternal bloodstream, giving rise to a symptom of generalized itching
(subclinical jaundice). A woman who has had gallstones may have an increased
tendency for stone formation during pregnancy as a result of the increased
plasma cholesterol level and additional cholesterol incorporated in bile.
• Some pregnant women notice hypertrophy at their gum lines and bleeding of
gingival tissue when they brush their teeth. There also may be increased saliva
formation (hyperptyalism), probably as a local response to increased levels of
estrogen. This is an annoying but not a serious problem.
• A lower-than-normal pH of saliva may lead to increased tooth decay if tooth
brushing is not done conscientiously. This can be a problem for homeless women
or any women who do not have frequent access to a place to brush their teeth.

Urinary System
Like other systems, the urinary system undergoes specific physiologic changes during
pregnancy, including alterations in fluid retention and renal, ureter, and bladder
function. These changes, result from:
• Effects of high estrogen and progesterone levels
• Compression of the bladder and ureters by the growing uterus
• Increased blood volume that increases kidney production of more urine
• Postural influences
Musculoskeletal System
Calcium and phosphorus needs are increased during pregnancy because an entire fetal
skeleton must be built. As pregnancy advances, a gradual softening of a woman’s pelvic
ligaments and joints occurs to create pliability and to facilitate passage of the baby
through the pelvis at birth. This softening is probably caused by the influence of both
the ovarian hormone relaxin and placental progesterone. This excessive mobility of
joints can cause discomfort late in pregnancy, especially if there is a separation of the
symphysis pubis. Separation this way causes acute pain and makes walking difficult and
painful.

To change her center of gravity and make ambulation easier, a pregnant woman
tends to stand straighter and taller than usual. This stance is sometimes referred to as
the“pride of pregnancy.” Standing this way, with the shoulders back and the abdomen
forward, however, creates a lordosis (forward curve of the lumbar spine), which may
lead to chronic backache, particularly in older women (Cakmak, Ribeiro, & Inanir,
2016) (Box 10.9).

Nursing Care Planning to Empower a Family(Backache)

Backache is a common symptom of pregnancy because of the strain the extra
uterine weight puts on lower vertebrae. Common measures to relieve backache in
pregnancy include:
• Limit the use of high heels because they add to the natural lordosis of pregnancy.
• Try to rest daily with feet elevated.
• Walk with head high and pelvis straight.
• Pelvic rocking at the end of the day may relieve pain for the
night.

Backache should be reported if:

• It is experienced as waves of pain (i.e., could be preterm labor).
• There are accompanying urinary symptoms, such as frequency and pain on
urination (i.e., could be a urinary tract infection).
• The back is tender at the point of backache (i.e., could be pyelonephritis or a
kidney infection or a ruptured vertebrae).
• Rest doesn’t relieve it (i.e., could be a muscle strain).

Patients With Unique Concerns in Pregnancy

TRANSGENDER PATIENTS
Transgender men (men whose sex assigned at birth was female) may seek pregnancy.
Discontinuation of testosterone hormone therapy and the physiologic changes of
pregnancy will often bring up self-identity issues. Being a transgender or gender variant
individual can feel isolating, and this isolation can deepen during pregnancy. Many
transgender male patients will need extra support during the preconception time period
as well as during the pregnancy itself (Ellis, Wojnar, & Pettinato, 2014).

Transgender women (women whose sex assigned at birth was male) may really want
to carry a pregnancy and, with new medical research on uterus transplants, may be able
to do so. Uterus transplants are still in the early stages and have not yet been attempted
for transgender women (Murphy, 2015).
PATIENTS WITH DISABILITIES
Women with disabilities may also have specific concerns about how to care for
themselves during pregnancy and for their child when he or she is born, and they need a
careful assessment of their feelings about having a baby and any special adjustments
they may need to make during pregnancy (Horner-Johnson, Darney, Kulkarni-
Rajasekhara, et al., 2016). Assess if they are concerned their child may be born with
their disability. Research or ask a knowledgeable team member to be certain your
advice will be accurate before assuring them this is not apt to happen.

RESTLESS LEG SYNDROME AND CARPAL TUNNEL SYNDROME

Two other concerns that arise more frequently in pregnant women than others are
restless leg syndrome and carpal tunnel syndrome.

Carpal tunnel syndrome is named for the Greek word karpos meaning “wrist” and
the narrow space where the median nerve passes between the bones of the wrist.
Repetitive movements, such as typing or swinging a tennis racket, can irritate the nerve
resulting in sensations of pain, tingling, and numbness. Probably because of the effect
of the hormone relaxin secreted by the placenta, pregnant women seem to be more
susceptible to this condition than others (Meems, Truijens, Spek, et al., 2015). Actions
women can take to avoid the syndrome and usual therapy is discussed in Chapter 49.

Restless leg syndrome is the uncontrollable urge to move the legs, often accompanied
by itching, tingling, or aching to such an extent a person has difficulty falling or staying
asleep (Oyieng’o, Kirwa, Tong, et al., 2016). It tends to occur more often in pregnant
women and people with iron deficiency than others.