Health Promotion During Pregnancy For these reasons, daily tub baths or showers are

recommended. Women should not soak for long

Women in prenatal care settings create an ideal periods in extremely hot water or in hot tubs,
teaching audience because the average woman is however, as heat exposure for a lengthy time could
eager to learn more about her pregnancy and the lead to hyperthermia in the fetus and birth defects,
steps she can take to maintain health during specifically esophageal atresia, omphalocele, and
pregnancy. gastroschisis
In addition to general health teaching, good role A woman may have difficulty maintaining her balance
modeling, such as not smoking in prenatal settings when getting in and out of a bathtub. If so, she should
and exhibiting a healthy lifestyle including sound change to showering or sponge bathing for her own
nutrition and exercise, is important (Power, Wilson, safety. If membranes rupture or vaginal bleeding is
Hogan, et al., 2013). present, tub baths become contraindicated because
When planning teaching strategies, a woman’s there might be a danger of developing a uterine
receptiveness to instruction is key. Regardless of how infection.
excited and pleased a woman is about being pregnant, Breast Care
she can assimilate only so much information at one
time. It is important, therefore, to be selective about A general rule is: as her breast size increases, a
the health information you provide and include those woman should be certain to wear a firm, supportive
points most relevant to the individual woman. For bra with wide straps to spread breast weight across
example, you would want to discuss varicosity the shoulders.
prevention more for a woman with a history of
varicosities in a former pregnancy than for one who is Interestingly, evidence shows that a woman’s breasts
enlarge more if the fetus she carries is male than if
pregnant for the first time and is athletic. Keep in
mind that health measures taught must be the fetus is female.
maintained for an extended time—40 weeks. To help Assuming a woman plans on breastfeeding,
a woman follow changes for this long, choose recommend she choose bras suitable for this (open in
individualized priorities, so health advice is specific the front), so she can continue to use them after the
and meaningful. baby’s birth.
Also remember the basic tenet of teaching and At about the 16th week of pregnancy, colostrum
learning: Learning is enhanced when the information secretion begins in the breasts.
has direct and immediate application to that person.
This principle means devising a plan that spaces out Teach her to wash her breasts with clear tap water
health-promotion and health-maintenance (no soap, because that could be drying and cause her
information into two sections. The first should include nipples to crack) daily to remove the colostrum and
teaching those measures that are immediately reduce the risk of infection.
applicable; the second should come later and include
Constant moisture next to the breast nipples can
those measures that have relevance only toward the
cause nipple excoriation, pain, and fissuring.
end of pregnancy.

SELF-CARE NEEDS

Bathing Dental Care

During pregnancy, sweating tends to increase Without adequate brushing, gingival tissue tends to
because a woman excretes waste products for both hypertrophy and, unless a pregnant woman brushes
herself and the fetus. She also has an increase in her teeth well, pockets of plaque form readily
vaginal discharge. between the swollen gum line and teeth, possibly
leading to periodontal diseases.
When bacteria in the mouth interact with sugar, this • Coitus on the expected due date does not initiate
lowers the pH of the mouth, creating an acid labor.
medium that can lead to etching or destruction of the
• Orgasm does not initiate preterm labor.
enamel of teeth

Encourage pregnant women to see their dentists • Coitus does not cause rupture of the membranes.
regularly for routine examination and cleaning.

If a woman has trouble avoiding sweet snacks such as Women whose membranes have ruptured or who
candy, suggest eating snacks that dissolve easily (like have vaginal spotting should be advised against
a chocolate bar) rather than one that remains in the coitus until examined by their primary care provider
mouth a long time (like chewy caramel). to prevent possible infection or complications related
Perineal Hygiene to a malpositioned placenta (placenta previa). Also
caution about partner oral–female genital contact
Women have increased vaginal discharge during because accidental air embolism has been reported
pregnancy and so need to maintain good perineal from this act during pregnancy as well as in the
hygiene. Caution them to always wipe front to back postpartal period from air entering open or fragile
after voiding to prevent bringing contamination uterine arteries. Anal sex may be uncomfortable
forward from the rectum. because of pregnancy-related hemorrhoids. In
addition, the act may allow bacteria to spread from
vaginal discharge seems excessive, douching is the rectum to the vagina. Changes in sexual position
contraindicated because the force of the irrigating may be needed to increase comfort.
fluid could cause the solution to enter the cervix,
leading to a uterine infection. In addition, douching Caution women with a nonmonogamous male sexual
alters the pH of the vagina, leading to an increased partner that the partner needs to use a condom to
risk of vaginal bacterial growth. prevent transmission of a sexually transmitted
infection during pregnancy
Clothing
EXERCISE
Maternity clothing should be comfortable. Women
should be cautioned to avoid garters, extremely firm Extreme exercise in women has been associated with
girdles with panty legs, and knee-high stockings during difficulty conceiving but after pregnancy occurs,
pregnancy because these may impede lower moderate exercise is healthy.
extremity circulation. Suggest wearing shoes with a
moderate-to-low heel to minimize pelvic tilt and During pregnancy, exercise can offer a general sense
of well-being. It also helps prevent circulatory stasis
possible backache as well as to reduce the risk of
falling. in the lower extremities.

As a rule, average, well-nourished women should

SEXUAL ACTIVITY
exercise during pregnancy about three times weekly
It is true that semen contains abundant for 30 consecutive minutes
prostaglandins, which can act to help soften a cervix
and ready it for labor, but whether the amount in a Their exercise program should consist of 5 minutes of
warm-up exercises, an active “stimulus” phase of 20
single ejaculation combined with the slight amount of
oxytocin released with female orgasm is enough to minutes, and then 5 minutes of cool-down exercises.
Movements that exercise large muscle groups
begin cervical softening is unproven
rhythmically, such as walking, are best but the type of
Asking a woman at a prenatal visit if she has any activity chosen should depend on their interests
questions about sexual activity allows her to voice
concerns about coitus. The intensity of the exercise program depends on
cardiopulmonary fitness. Both pregnant and
You may need to replace myths with facts, such as: nonpregnant women should exercise at 70% to 85%
of their maximum heart rate. The easiest way to To obtain enough sleep and rest during pregnancy,
calculate this is for women to subtract their age from pregnant women may need to begin sleep earlier in
220 and then calculate 70% or 85% of that number. the evening as well as schedule a rest period during
the afternoon.
Beginning an exercise program during pregnancy not
only offers the advantage of being healthy during Pregnant women also have a higher incidence of
pregnancy but also provides long-term benefits such “restless leg syndrome” (waking at night because of
as: spontaneous leg movement) than nonpregnant
women.
• Lowering cholesterol levels
Frequent waking such as this can lead to loss of rapid
• Reducing the risk of osteoporosis eye movement (REM) sleep. Loss of REM sleep causes
• Increasing energy levels a woman to feel anxious and not well rested,

• Maintaining a healthy body weight Recommend sleeping with two or three pillows or on
a couch with an armrest in these instances.
• Decreasing the risk of heart disease

• Increasing self-esteem and well-being

EMPLOYMENT

Women who are unable to continue working are

SLEEP protected from loss of employment benefits during
pregnancy by federal law (Public Law 95-555) unless
optimal condition for body growth occurs when
they work for a company with fewer than 15
growth hormone secretion is at its highest level—that
employees. According to federal law, an employer
is, during sleep.
cannot:
Pregnant women rarely have difficulty falling asleep
• Deprive women of seniority rights, in pay or
at night because of this increased physiologic need for
promotion, because they take a maternity leave
sleep. If a woman does have trouble falling asleep,
drinking a glass of warm milk may help. • Treat women returning from maternity leave as new
hires, starting over on the eligibility period for pension
A good resting or sleeping position is a left-sided
and other benefits
Sims position, with the top leg forward
• Force pregnant women to leave their job if they are
This position puts the weight of the fetus on the bed,
able to and want to continue working
not on the woman, and allows good circulation in
lower extremities. • Refuse to hire women just because they are
pregnant or fire them for the same reason
Be certain a woman knows to avoid resting flat on
her back because supine hypotension syndrome (i.e., • Refuse to cover employees’ normal pregnancy and
faintness, diaphoresis, and hypotension from the birth expenses in the company health plan or pay less
pressure of the expanding uterus on the inferior vena for pregnancy than for other medical conditions
cava) can develop in this position.
• Refuse to pay sick leave or disability benefits to
If needed, placing a rolled pillow behind her can act women whose difficult pregnancies keep them off the
as a reminder not to turn onto her back. job

Sleep deprivation during pregnancy is associated not Some occupations are hazardous during pregnancy
only with fatigue in the woman but also with the and should be discontinued because they bring
possibility of growth restriction in her fetus. women into contact with harmful substances.
Other problems that can occur with employment against cholera or antibiotic prophylaxis for malaria
include interference with adequate rest and before they can safely enter certain countries.
nutrition.
The influenza vaccine is recommended if it is flu
Most women work to augment or supply family season (October through May) for all pregnant
income, not for fun. women.

TRAVEL

Early in a normal pregnancy, there are no restrictions

unless the woman needs to travel to a malaria-prone,
Zika virus, or other at-risk region (where she would
need vaccine protection).

Suggest she use a “sea-sick” wrist or acupuncture

band for this instead.

Late in pregnancy, travel plans should take into

consideration the possibility of early labor, requiring
birth at a strange setting where a woman’s obstetric
history will be unknown.

Advise a woman who is taking a long trip by

automobile to plan for frequent rest or stretch
periods. Preferably every hour, but at least every 2
hours, she should get out of the car and walk a short
distance. This break relieves stiffness and muscle Lightening
aches and improves lower extremity circulation,
helping prevent varicosities, hemorrhoids, and Descent of the fetal presenting part (usually the fetal
thrombophlebitis. head) into the pelvis, occurs approximately 10 to 14
days before labor begins. This fetal descent changes
Pregnant women may drive automobiles as long as a woman’s abdominal contour because it positions
they fit comfortably behind the steering wheel. They the uterus lower and more anterior in the abdomen.
should use seat belts like everyone else. Lightening gives a woman relief from the
diaphragmatic pressure and shortness of breath she
Both shoulder harnesses and lap belts should be used.
has been experiencing and in this way “lightens” her
The lap belt should be worn as snugly as comfortable
load. Lightening probably occurs early in primiparas
so that it fits under the abdominal bulge and across
this way because of tight abdominal muscles. In
the pelvic bones. The shoulder harness should be snug
multiparas, it is not as dramatic and usually occurs
but comfortable, worn across the shoulder, chest, and
on the day of labor or even after labor has begun.
upper abdomen. A pad may be placed under the
shoulder harness at the neck to avoid chafing Increase in Energy

Some airlines do not permit women who are more A woman may awaken on the morning of labor full of
than 7 months pregnant to board; others require energy, in contrast to the feeling of chronic fatigue
written permission from her provider that she has been feeling for the previous month. This
increase in activity is related to a boost in
Traveling by plane for women is not contraindicated
epinephrine release, which is initiated by a decrease
during pregnancy as long as the plane has a well-
in progesterone production by the placenta. This
pressurized cabin.
additional epinephrine prepares a woman’s body for
Women who travel abroad may need additional the work of labor ahead.
safety measures such as a vaccine for protection
Slight Loss of Weight The typical time for this is when contractions are 5
minutes apart, but this will vary depending on a
As progesterone level falls, body fluid is more easily woman’s past and present pregnancy history.
excreted from the body. This increase in urine
production can lead to a weight loss between 1 and 3 Show
lb.
As the cervix softens and ripens, the mucus plug that
Backache filled the cervical canal during pregnancy is expelled.
The exposed cervical capillaries seep blood as a result
Because labor contractions begin in the back, an of pressure exerted by the fetus. This blood, mixed
intermittent backache stronger than usual may be the with mucus, takes on a pink tinge and is referred to as
first symptom a woman notices. “show” or “bloody show.” Women need to be aware
Braxton Hicks Contractions of this event so they do not think they are bleeding
abnormally.
In the last week or days before labor begins, a
woman usually notices extremely strong Braxton Hicks Rupture of the Membranes
contractions. Labor may begin with rupture of the membranes,
A woman having her first child may have such experienced either as a sudden gush or as a scanty,
difficulty distinguishing between these and true slow seeping of clear fluid from the vagina. Some
contractions that she may come to the labor unit of a women may worry if their labor begins with a
hospital or birthing center believing she is in labor. rupture of the membranes because they have heard
labor will then be “dry,” and this will cause it to be
strong Braxton Hicks contractions cause true difficult and long. Actually, amniotic fluid continues
discomfort to be produced until delivery of the membranes after
the birth of their child, so no labor is ever “dry.” Early
Ripening of the Cervix
rupture of the membranes can actually be
Ripening of the cervix is an internal sign seen only on advantageous as it can cause the fetal head to settle
pelvic examination. Throughout pregnancy, the snugly into the pelvis, aiding cervical dilation and
cervix feels softer than usual to palpation, similar to shortening labor.
the consistency of an earlobe (Goodell’s sign). At
term, the cervix becomes still softer (described as
“butter soft”), and it tips forward. Cervical ripening
this way is an internal announcement that labor is
very close at hand.

SIGNS OF TRUE LABOR

Signs of true labor involve both uterine and cervical

changes.

Uterine Contractions

True labor contractions usually begin in the back and

sweep forward across the abdomen similar to the
tightening of a rubber band. They gradually increase
in frequency and intensity over a period of hours.
Because contractions are involuntary and come
without warning, their intensity can be frightening in
early labor.
 Leopold maneuvers are a systematic method of
observation and palpation to determine fetal
presentation and position and are done as part of a
physical examination.

Abdominal and Lower Leg Assessment

Assessing a woman’s abdomen is important to

estimate fetal size by fundal height (which should be
THE INITIAL FETAL ASSESSMENT at the level of the xiphoid process at term). Palpate
and percuss the bladder area (over the symphysis
Although fairly passive in labor, a fetus is subjected to
pubis) to detect a full bladder. Assess for abdominal
extreme pressure by uterine contractions and passage
scars to reveal previous abdominal or pelvic surgery
through the birth canal, so it is important to ascertain
that could have left adhesions. Finally, inspect lower
that the FHR remains within normal limits despite
extremities for skin turgor to assess hydration and
these pressures. Auscultation of Fetal Heart Sounds
also for edema and varicose veins. Women with large
Fetal heart sounds are transmitted best through the
varicosities are more prone to thrombophlebitis after
convex portion of a fetus because that is the part that
birth than other women. Severe edema suggests
lies in closest contact with the uterine wall.
hypertension of pregnancy. A blood pressure 140/90
• In a vertex or breech presentation, fetal heart mmHg or higher can confirm this.
sounds are usually best heard through the fetal back.
NON STRESS TEST
• In a face presentation, the back becomes concave so
the sounds are best heard through the more convex If labor has not begun by 41 weeks, a nonstress test,
thorax. and/or a biophysical profile may be done to document
• In breech presentations, fetal heart sounds are the state of placental perfusion and the amount of
heard most clearly high in the uterus, at a woman’s amniotic fluid present. If these are normal, it suggests
umbilicus or above. the due date was miscalculated. If the test results are
• In cephalic presentations, they are heard loudest abnormal or the physical examination or biparietal
low in a woman’s abdomen. diameter measured on ultrasound suggests the fetus
• In an ROA position, sounds are heard best in the is term size, labor will be induced.
right lower quadrant.
• In an LOA position, sounds are heard best in the left Nonstress Testing
lower quadrant.
A nonstress test measures the response of the fetal
• In posterior positions (LOP or ROP), heart sounds
heart rate to fetal movement. Position the woman
may be loudest at a woman’s
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.

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.
Leopold Maneuvers
If a 20-minute period passes without any fetal hemorrhage, and infant mortality is higher in women
movement, it may only mean that the fetus is who have a prolonged labor than in those who do not.
sleeping, although other reasons for lessened Therefore, it is vital to recognize and prevent
variability are maternal smoking, drug use, or dysfunctional labor to the extent possible.
hypoglycemia.
Prolonged labor appears to result from several
Both rhythm strip and nonstress testing are factors but is most likely to occur if a fetus is large or
noninvasive procedures and cause no risk to either if the contractions are hypotonic, hypertonic, or
the pregnant woman or fetus, they can be used as uncoordinated contractions occur.
screening procedures in all pregnancies. They can be
INEFFECTIVE UTERINE FORCE
conducted at home daily as part of a home monitoring
program for the woman who is having a complication Uterine contractions are the basic force that moves
of pregnancy. If a nonstress test is nonreactive, an the fetus through the birth canal. They occur because
additional fetal assessment, such as a biophysical of the interplay of the contractile enzyme adenosine
profile test, will be scheduled. triphosphate and the influence of major electrolytes
such as calcium, sodium, and potassium, specific
contractile proteins (actin and myosin), epinephrine
A contraction stress test and norepinephrine, oxytocin (a posterior pituitary
hormone), estrogen, progesterone, and
checks to see if your baby will stay healthy during prostaglandins. In about 95% of labors, contractions
contractions when you are in labor. This test includes follow a predictable, efficient course. When they have
external fetal heart monitoring. The test is done when less strength than usual or are rapid but ineffective,
you are 34 or more weeks pregnant. During a dysfunctional labor occurs.
contraction, the blood and oxygen supply to your
baby drops for a short time. With hypotonic uterine contractions,

the number of contractions is unusually infrequent

(not more than two or three occurring in a 10-
Although labor often proceeds without any deviation minute period). The resting tone of the uterus
from the normal, many potential complications can remains less than 10 mmHg, and the strength of
occur. A difficult labor—dystocia—can arise from any contractions does not rise above 25 mmHg (Fig.
of the four main components of the labor process: 23.1B). Hypotonic contractions occur during the
(a) the power, or the force that propels the fetus active phase of labor and tend to occur after the
(uterine contractions); administration of analgesia, especially if the cervix is
not dilated to 3 to 4 cm or if bowel or bladder
(b) the passenger (the fetus); distention is preventing descent or firm engagement.
They also may occur in a uterus that is overstretched
(c) the passageway (the birth canal); or
by a multiple gestation, a larger than usual single
(d) the psyche (the woman’s and family’s perception fetus, polyhydramnios, or in a uterus that is lax from
of the event) grand multiparity.

Complications With the Power (The Force of Labor) Hypotonic contractions will increase the length of
labor because more of them are necessary to achieve
Inertia is a time-honored term to denote sluggishness cervical dilatation.
of contractions, or that the force of labor, is less than
usual. A more current term is dysfunctional labor.

Dysfunction can occur at any point in labor, but it is Hypertonic uterine contractions
generally classified as primary (i.e., occurring at the
are marked by an increase in resting tone to more
onset of labor) or secondary (i.e., occurring later in
than 15 mmHg (Fig. 23.1C). However, the intensity of
labor). The risk of maternal postpartal infection,
the contraction may be no stronger than that
associated with hypotonic contractions. In contrast to repolarization occurs; relaxation or a low resting
hypotonic contractions, these occur frequently and tone is achieved; and another pacemaker-activated
are most commonly seen in the latent phase of contraction begins. With uncoordinated contractions,
labor. more than one pacemaker may be initiating
contractions, or receptor points in the myometrium
Hypertonic contractions may be acting independently of the pacemaker.
- may occur because more than one uterine Uncoordinated contractions can occur so closely
pacemaker is stimulating contractions or together that they can interfere with the blood supply
because the muscle fibers of the to the placenta. Because they occur so erratically,
myometrium do not repolarize or relax after such as one on top of another and then a long period
a contraction, thereby “wiping it clean” to without any, it may be difficult for a woman to rest
accept a new pacemaker stimulus. between contractions or to breathe effectively with
contractions.
A danger of hypertonic contractions

is that the lack of relaxation between contractions

may not allow optimal uterine artery filling; this can PRECIPITATE LABOR
lead to fetal anoxia early in the latent phase of labor. Precipitate dilatation is cervical dilatation that occurs
at a rate of 5 cm or more per hour in a primipara or
10 cm or more per hour in a multipara. Precipitate
birth occurs when uterine contractions are so strong a
woman gives birth with only a few, rapidly occurring
contractions, often defined as a labor that is
completed in fewer than 3 hours (Suzuki, 2016). Such
rapid labor is likely to occur with grand multiparity, or
it may occur after induction of labor by oxytocin.
Contractions can be so forceful they lead to
premature separation of the placenta or lacerations of
the perineum, placing the woman at risk for
haemorrhage

A precipitate labor can be predicted from a labor

graph if, during the active phase of dilatation, the rate
is greater than 5 cm/hr (1 cm every 12 minutes) in a
nullipara or 10 cm/hr (1 cm every 6 minutes) in a
multipara.

INDUCTION AND AUGMENTATION OF LABOR

augmentation of labor with oxytocin or amniotomy

Induction of labor means labor is started artificially.

Augmentation of labor refers to assisting labor that

has started spontaneously but is not effective. \

Uncoordinated Contractions
Augmentation of labor may be used if labor
Normally, all contractions are initiated at one contractions begin spontaneously but then become
pacemaker point high in the uterus. A contraction weak, irregular, or ineffective (i.e., hypotonic)
sweeps down over the organ, encircling it; (Rossen, Østborg, Lindtjørn, et al., 2016). Precautions
regarding oxytocin augmentation are the same as for
primary oxytocin induction of labor. Be certain the
drug is increased in small increments only and that
fetal heart sounds are well monitored during the
procedure. Box 23.5 shows an interprofessional care
map illustrating both nursing and team planning
during an augmented labor.

Although induction may be necessary to initiate labor

before the time when it would have occurred
spontaneously because a fetus is in danger, it is not
used as an elective procedure until the fetus is at term
(over 39 weeks). At one time, induction could be
completed if a fetus was proven to have adequate
lung surfactant by amniocentesis at term but less than
39 weeks.