Fetal Growth and Development Guide PDF

Supplement for fetal growth and development MILESTONES OF FETAL GROWTH AND 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 o...

Supplement for fetal growth and development MILESTONES OF FETAL GROWTH AND 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 (Fig. 9.7) [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 the pregnant person 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 pregnant person'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 pregnant person 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., people having their first baby), the fetus often sinks into the birth canal during the last 2 weeks of pregnancy, giving the pregnant person a feeling the load they are carrying is less. This event, termed lightening, is a fetal announcement that the fetus is in a ready position and birth is nearing **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 **Typically, tape measurement from the notch of the symphysis pubis to over the top of the uterine fundus as a pregnant patient 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 (see Chapter 21). 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 rule becomes inaccurate during the third trimester of pregnancy because the fetus is growing more in weight than in height during this time 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 pregnant person (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 patients 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, 2018). Make certain the patient knows fetal movements do vary, especially in relation to sleep cycles, their activity, and the time since they last ate. Otherwise, they can become unduly worried the fetus is in jeopardy when the fetus is asleep or just having an inactive time [Nonstress Testing ] A nonstress test measures the response of the fetal heart rate to fetal movement. Position the patient and attach both a fetal heart rate and a uterine contraction monitor. Instruct the patient to push the button attached to the monitor (similar to a call bell) whenever they feel 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 per minute 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 six beats per minute) throughout the testing period (Gavin & Baschat, 2021). 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 patient an oral carbohydrate snack, such as orange juice, it can cause the 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 person 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 person 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 pregnant person's abdomen to produce a sharp sound of approximately 80 dB at a frequency of 80 Hz, thus startling and waking the fetus (Gavin & Baschat, 2021). 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 birthing parent. 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 patient's electronic health record; a copy of the scan can be offered 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 the fetus is well or whole can be greatly reassured by viewing such a sonogram image. Before an ultrasound examination, be certain a patient 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 a partner 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 patient has a full bladder at the time of the procedure. To ensure this, ask them 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 patient up to an examining table and drape them for modesty, but with their abdomen exposed. To prevent supine hypotension syndrome, place a towel under the right buttock to tip the body slightly so the uterus will roll away from the vena cava. A gel is then applied to the 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 the 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 pregnant patient 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 may be, however, caution 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 patients 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 (Frusca et al., 2018). 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 chromosomal 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 (ACOG, 2014). 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 (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 (Gavin & Baschat, 2021). 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 pregnant patient, MRI has the potential to replace or complement ultrasonography as a fetal assessment technique because it can identify structural anomalies or soft tissue disorders (Lum & Tsiouris, 2020). 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 patient as well as the fetus. Maternal Serum Alpha-Fetoprotein Close to 0.5% of conceptions result in a fetus that has the trisomy 21 defect. It is more frequent in pregnant people with advanced maternal age. Down syndrome can be identified in the first or early second trimester through maternal serum testing for alpha-fetoprotein (MSAFP) and other biomarkers as previously discussed. Prenatal diagnosis with high sensitivity and specificity can be achieved by assaying fetal DNA that is circulating in maternal blood (Pyeritz, 2021). 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 pregnant person. Because it measures four separate values, it is the most common of the maternal serum tests used today (Manipalviratn et al., 2019) Fetal Sex Although fetal sex is usually determined by an ultrasound screen at about 4 months, it can be determined as early as 10 weeks by analysis of maternal serum. This early diagnosis could be helpful to a pregnant patient who has an X-carrying genetic disorder to discover if a male fetus could inherit the disease or a female fetus will be disease-free (Zheng et al., 2020) **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 7). If the pregnant patient 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 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 dilatation 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 pregnant person'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) A. 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 Rh-negative patients 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 pregnant patient over amniocentesis and can yield information not available by any other means, especially about blood dyscrasias B. 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 (Graves et al., 2017). 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. Additionally, fetoscopy is used for placental laser surgery in twin-to-twin transfusion syndrome (Graves et al., 2017). The earliest time in pregnancy a fetoscopy can be performed is approximately the 16th or 17th week. For the procedure, the pregnant person 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 patient 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 pregnant patient 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 pregnant person's autonomy being compromised by fetal needs if further procedures are necessary such as asking the pregnant patient to undergo general anesthesia so the fetus can have surgery The Psychological Tasks of Pregnancy During the 9 months of pregnancy, a pregnant person and their partner run a gamut of emotions, ranging from surprise at finding out about the pregnancy (or wishing they 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, parents may feel surprised again that the pregnancy is over and they really do have a child FIRST TRIMESTER: ACCEPTING THE PREGNANCY The Pregnant Person The task of a pregnant person 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 45% of pregnancies are still unintended, unwanted, or mistimed (Finer & Zolna, 2016). Because no one can be absolutely confident in advance that they will be able to conceive until it happens, even planned pregnancies are a surprise to some extent because people can be amazed it either happened so quickly or took so long. Following their initial surprise, pregnant people 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 person is left feeling nothing. Instead, it refers to the interwoven feelings of wanting and not wanting, feelings that can be confusing to an ordinarily organized person. Before fetal movement is felt, most patients have an ultrasound to help set the dates of the pregnancy or screen for genetic anomalies around 8 to 14 weeks of pregnancy. Another routine sonogram between 18 and 22 weeks to assess for anatomic anomalies is also completed. These sonograms can be a major step in promoting acceptance because patients can see a beating heart or a fetal outline or can learn the sex of their fetus. Many patients 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 (Thomas et al., 2017). Although most pregnant people 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, patients 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 person realizes they are pregnant or comes for a first prenatal visit, the sooner they can begin to safeguard fetal health by measures such as discontinuing all drugs not specifically prescribed or approved by the primary healthcare provider (Bastaki et al., 2020). 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 health of their partner. A female partner to the pregnant patient 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 pregnant person in their changed state. Like the pregnant patient, 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 either partner 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 pregnant person's time and thought (Darwin et al., 2017). Remember, once partners feel an attachment to a coming child, they can then feel as deep a sense of loss as the pregnant person 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 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 Pregnant Person During the second trimester, the psychological task of a pregnant person is to accept they are having a baby, a step up from accepting the pregnancy. This change usually happens at quickening, or the first moment a pregnant person feels fetal movement. Until a person experiences this proof of the child's existence, and although they ate to meet nutritional needs and took special vitamins to help the fetus grow, it seemed more like just another part of their own body. With quickening, the fetus becomes a separate identity. A person may then imagine themselves as a parent, teaching their child the alphabet or how to ride a bicycle. This anticipatory role playing is an important activity for midpregnancy as it leads to a greater concept of their condition and helps them realize they are more than just pregnant---there is a separate human being inside them. People often use the term "it" or "they" to refer to their fetus before quickening but begin to use he or she afterward. Some women continue to use it or they, however, so doing so is not a sign of poor attachment but an individual preference as some people believe referring to the child as "she" or "he" will bring bad luck or disappointment if the sonogram report was wrong. Additionally, many couples choose not to find out the sex of the baby and so may continue to use these alternative pronouns until delivery. Lastly, there are couples who do not believe in the binary construct of gender and will continue to avoid using "she" and "he" pronouns, even after the child is born. Most people can pinpoint a moment during each pregnancy when they knew they definitely wanted their child. The firmer this attachment, the less likely they are to experience postpartum depression (Petri et al., 2018). For a person who carefully planned the pregnancy, this moment of awareness may occur as soon as they recover from the surprise of learning they have actually conceived. For others, it may come when they announce the news to their parents and hear them express their excitement or when they see a look of pride on their 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 birthing parent first hears the baby's cry or feeds the newborn. If a person has a complication of pregnancy, it could take several weeks after the baby is born for them to accept that the birth was real and to come to terms with parenthood. A good way to measure the level of a patient's acceptance of their coming baby is to measure how well they follow prenatal instructions. Until a person views the growing life inside as something desired, it may be difficult to substitute a high-protein food for a favorite high-calorie coffee drink, for instance. After all, until the abdomen begins to enlarge, gaining weight may be the most certain proof that there is a growing pregnancy The Partner As the pregnant partner begins to actively prepare for the coming baby, the other partner increasingly may feel as if they are 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 that the pregnant person 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 partner most needs emotional support. In a cisgender, heterosexual relationship, some men may have difficulty enjoying the pregnancy because they have been misinformed about sexuality, pregnancy, and female reproductive health. A man might believe, for example, that breastfeeding will make his partner's breasts no longer attractive or that after birth, sexual relations will no longer be enjoyable. It is important 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, people 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 of completing the third trimester task of pregnancy or preparing for parenthood. People at this point are usually interested in attending prenatal classes and/or classes on preparing for childbirth. It's helpful to ask expecting parents 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 people 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 childcare (Barimani et al., 2018). Chapter 14 discusses the usual curriculum of childbirth and parenthood education classes. Although pregnancy is a happy time for most parents, 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 (Petri et al., 2018) (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 people reveal when asked these questions. An interprofessional approach (e.g., referral to a nutritionist, a primary healthcare provider, social services) is often necessary to help solve some of these multifaceted problems.   CHANGES DURING PREGNANCY BY SYSTEMS  INTEGUMENTRAY  CARDIOVASCULAR  Gastrointestinal System At least 50% of pregnant people experience some nausea and vomiting early on in pregnancy. For many, this is the first sensation they experience 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 person 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 pregnant person may have a voracious appetite (Dekkers et al., 2020). Many alternate or complementary methods to help reduce nausea are available, such as acupuncture or wrist bands (discussed in Chapter 13). Box 10.8 is an interprofessional care map illustrating both nursing and team planning for a patient with nausea of pregnancy URINARY SYSTEM 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 pregnant person'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 the center of gravity and make ambulation easier, a pregnant person 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),