Maternal Emotional Responses

Ambivalence
The realization of a pregnancy can lead to fluctuating responses, possibly at the opposite ends of the spectrum. For example, regardless of
whether the pregnancy was planned, the woman may feel proud and excited at her achievement while at the same time fearful and anxious
of the implications. The reactions are influenced by several factors, including the way the woman was raised, her current family situation,
the quality of the relationship with the expectant father, and her hopes for the future. Some women express concern over the timing of the
pregnancy, wishing that goals and life objectives had been met before becoming pregnant. Other women may question how a newborn or
infant will affect their career or their relationships with friends and family. These feelings can cause conflict and confusion about the
pregnancy. Ambivalence, or having conflicting feelings at the same time, is a universal feeling and is considered normal when preparing for
a lifestyle change and new role. Pregnant women commonly experience ambivalence during the first trimester. Usually ambivalence
evolves into acceptance by the second trimester, when fetal movement is felt. The woman’s personality, her ability to adapt to changing
circumstances, and the reactions of her partner will affect her adjustment to being pregnant and her acceptance of impending motherhood.

Introversion
Introversion, or focusing on oneself, is common during the early part of pregnancy. The woman may withdraw and become increasingly
preoccupied with herself and her fetus. As a result, her participation with the outside world may be less, and she will appear passive to her
family and friends. This introspective behavior is a normal psychological adaptation to motherhood for most women. Intro version seems to
heighten during the first and third trimesters, when the woman’s focus is on behaviors that will ensure a safe and health pregnancy
outcome. Couples need to be aware of this behavior and should be informed about measures to maintain and support the focus on the
family.

Acceptance
During the second trimester, the physical changes of the growing fetus with an enlarging abdomen and fetal movement bring reality and
validity to the pregnancy. There are many tangible signs that someone separate from herself is present. The pregnant woman feels fetal
movement and may hear the heartbeat. She may see the fetal image on an ultrasound screen and feel distinct parts, recognizing independent
sleep and wake patterns. She becomes able to identify the fetus as a separate individual and accepts this. Many women will verbalize
positive feelings about the pregnancy and will conceptualize the fetus. The woman may accept her new body image and talk about the new
life within. Generating a discussion about the woman’s feelings and offering support and validation at prenatal visits are important.

Mood Swings
Emotional lability is characteristic throughout most pregnancies. One moment a woman can feel great joy, and within a short time she can
feel shock and disbelief. Frequently, pregnant women will start to cry without any apparent cause. Some women feel as though they are
riding an “emotional roller-coaster.” These extremes in emotion can make it difficult for partners and family members to communicate with
the pregnant woman without placing blame on themselves for their mood changes. Clear explanations about how common mood swings are
during pregnancy are essential.
Change in Body Image
The way in which pregnancy affects a woman’s body image varies greatly from person to person. Some women feel as if they have never
been more beautiful, whereas others spend their pregnancy feeling overweight and uncomfortable. For some women pregnancy is a relief
from worrying about weight, whereas for others it only exacerbates their fears of weight gain. Changes in body image are normal but can be
very stressful for the pregnant woman. Offering a thorough explanation and initiating discussion of the expected bodily changes may help
the family to cope with them.

Maternal Role Tasks

• Ensuring safe passage throughout pregnancy and birth
• Primary focus of the woman’s attention
• First trimester: woman focuses on herself, not on the fetus
• Second trimester: woman develops attachment of great value to her fetus
• Third trimester: woman has concern for herself and her fetus as a unit
• Participation in positive self-care activities related to diet, exercise, and overall well-being
• Seeking acceptance of infant by others
• First trimester: acceptance of pregnancy by herself and others
• Second trimester: family needs to relate to the fetus as member
• Third trimester: unconditional acceptance without rejection
• Seeking acceptance of self in maternal role to infant (“binding in”)
• First trimester: mother accepts idea of pregnancy, but not of infant
• Second trimester: with sensation of fetal movement (quickening), mother acknowledges fetus as a separate entity within her
• Third trimester: mother longs to hold infant and becomes tired of being pregnant
• Learning to give of oneself
• First trimester: identifies what must be given up to assume new role
• Second trimester: identifies with infant, learns how to delay own desires
• Third trimester: questions her ability to become a good mother to infant (Rubin, 1984)

Pregnancy and Sexuality

The way a pregnant woman feels and experiences her body during pregnancy can affect her sexuality. The woman’s changing shape,
emotional status, fetal activity, changes in breast size, pressure on the bladder, and other discomforts of pregnancy result in increased
physical and emotional demands. These can produce stress on the sexual relationship between the pregnant woman and her partner. As the
changes of pregnancy ensue, many partners become confused, anxious, and fearful of how the relationship may be affected. Sexual desire
of pregnant women may change throughout the pregnancy. During the first trimester, the woman may be less interested in sex because of
fatigue, nausea, and fear of disturbing the early embryonic development. During the second trimester, her interest may increase because of
the stability of the pregnancy. During the third trimester, her enlarging size may produce discomfort during sexual activity (Frieden &
Chan, 2007). A woman’s sexual health is intimately linked to her own self-image. Sexual positions to increase comfort as the pregnancy
progresses as well as alternative noncoital modes of sexual expression, such as cuddling, caressing, and holding, should be discussed.
Giving permission to talk about and then normalizing sexuality can help enhance the sexual experience during pregnancy and, ultimately,
the couple’s relationship. If avenues of communication are open regarding sexuality during pregnancy, any fears and myths the couple may
have can be dispelled.

Pregnancy and the Partner

Nursing care related to childbirth has expanded from a narrow emphasis on the physical health needs of the mother and infant to a broader
focus on family-related, social and emotional needs. One prominent feature of this family-centered approach is the recent movement toward
promoting the mother–infant bond. To achieve a truly family-centered practice, nursing must make a comparable commitment to
understanding and meeting the needs of the partner in the emerging family. Recent studies suggest that the partner’s potential contribution
to the infant’s overall development has been misperceived or devalued and that the partner’s ability and willingness to assume a more
active role in the infant’s care may have been underestimated. Reactions to pregnancy and to the psychological and physical changes by the
woman’s partner vary greatly. Some enjoy the role of being the nurturer, whereas others experience alienation and may seek comfort or
companionship elsewhere. Some expectant fathers may view pregnancy as proof of their masculinity and assume the dominant role,
whereas others see their role as minimal, leaving the pregnancy up to the woman entirely. Each expectant partner reacts uniquely.
Emotionally and psychologically, expectant partners may undergo less visible changes than women, but most of these changes remain
unexpressed and unappreciated (Thies & Travers, 2006). Expectant partners also experience a multitude of adjustments and concerns.
Physically, they may gain weight around the middle and experience nausea and other GI disturbances—what is termed couvade syndrome,
a sympathetic response to their partner’s pregnancy. They also experience ambivalence during early pregnancy, with extremes of emotions
(e.g., pride and joy versus an overwhelming sense of impending responsibility). During the second trimester of pregnancy, partners go
through acceptance of their role of breadwinner, caretaker, and support person. They come to accept the reality of the fetus when movement
is felt, and they experience confusion when dealing with the woman’s mood swings and introspection. During the third trimester, the
expectant partner prepares for the reality of this new role and negotiates what the role will be during the labor and birthing process. Many
express concern about being the primary support person during labor and birth and worry how they will react when faced with their loved
one in pain. Expectant partners share many of the same anxieties as their pregnant partners. However, it is uncommon for them to reveal
these anxieties to the pregnant partner or health care professionals. Often, how the expectant partner responds during the third trimester
depends on the state of the marriage or partnership. When the marriage or partnership is struggling, the impending increase in responsibility
toward the end of pregnancy acts to drive the expectant partner further away. Often it manifests as working late, staying out late with
friends, or beginning new or superficial relationships. In the stable marriage or partnership, the expectant partner who may have been
struggling to find his or her place in the pregnancy now finds concrete tasks to do for example, painting the nursery, assembling the car
seat, attending Lamaze classes, and so on.

FACTORS THAT INTERFERE WITH PSYCHOSOCIAL ADAPTATIONS DURING PREGNANCY

Grief and loss during the perinatal period can be triggered by spontaneous abortion; elective termination; plans to relinquish the child for
adoption or surrogacy; and loss of the perfect child through prematurity, illness, deformity, or less preferred gender. Parental reactions can
produce a separation from the infant and delay attachment, prompt feelings of personal inadequacy concerning the inability to produce a
healthy infant, and alter healthy methods of relating to the infant. The importance of prenatal education, labor and birth preparation, and
parenting classes cannot be stressed enough by the nurse. Many women bypass the courses offered by their health care providers or
hospitals in lieu of watching birth stories on television. These programs are a good adjunct but must be placed into context by information
obtained at the prenatal visits and during attendance at prenatal and childbirth education classes taught by nurses and certifi ed personnel.

NURSING ASSESSMENT OF PSYCHOSOCIAL CHANGES AND PRENATAL HEALTH EDUCATION

Nursing assessment of the psychosocial changes that occur during pregnancy must include a thorough history including the family
background, past obstetrical events, and the status of the current pregnancy. Each prenatal visit provides an opportunity to ask the patient
about her pregnancy experience since the last visit, address current concerns, and offer anticipatory guidance of what to expect from the
present visit to the next appointment. Based on this information, the nurse formulates appropriate nursing diagnoses related to the maternal
psychosocial adaptation to pregnancy (Box 8-2). Health education should be focused according to the current trimester and evaluated by the
patient’s or couple’s ability to verbalize the content presented, their efforts to seek assistance and support with psychological concerns, and
indicators of satisfactory coping with the psychological transitions that are occurring. Suggested topics for health teaching during each
trimester are presented in Table 8-5. Pregnancy represents a time of great physical and emotional change. The woman and her family
require ongoing support and education to ensure that they safely and successfully move through the stages of pregnancy and, in the end, are
prepared to welcome the new baby into their lives.

Factors Affecting Adaptation:

• Absence of significant others
• Pregnancy in adolescence
• Cultural and societal influences
• High-tech management

Family Adaptations:
• Reorganization of the home; realignment of duties
• Change in money management
• Interfamily role change: child to parent
• Incorporation of each new child into existing family structure

Maternal Adaptations:
• Incorporation of pregnancy into self-concept: fetal embodiment
• Unconditional acceptance of child
• Reorder relationships  accommodate child into family structure
• Nesting
• Participation in labor and birth
• Work through post-birth doubts

Paternal Adaptations
• Varying degrees of involvement
– Observer; expressive; instrumental
• Corresponding tasks: by trimesters
– Announcement phase: acceptance
– Moratorium phase: “binding in”
– Focusing phase: increased involvement; role clarification
• Couvade syndrome

Factors that Interfere with Adaptation

• Termination of pregnancy
– Spontaneous abortion/elective termination
• Plan to relinquish child
• Loss of the “perfect” child