10.3 Common Discomforts of Pregnancy

Nausea and Vomiting

Nausea and vomiting, commonly called morning sickness, are expected discomforts most frequently experienced starting around weeks 4 to 6 of gestation and fading away by 16 weeks of gestation. Nausea and vomiting are linked to the changes in motility within the digestive system and the higher serum levels of estrogen, progesterone, and hCG in the first part of the pregnancy.

Patient education to relieve nausea and vomiting includes eating small, frequent snacks every 1 to 2 hours while awake and not drinking fluids immediately before, during, or after eating. Ginger tea, ginger ale, and lemonade have proved effective in relieving nausea. Consuming dry toast, saltine crackers, or cold pasta and avoiding greasy or spicy foods have also been found to decrease the severity of nausea and vomiting in some pregnant persons. Sometimes the pregnant person has to find their own pattern of eating and specific foods to eat to find relief from the nausea and vomiting. Additional nonpharmacologic measures include increasing vitamin B6, using acupressure wrist bands, or taking prenatal vitamins at night.

Pharmacologic measures are prescribed to treat severe vomiting to prevent dehydration and weight loss. The most commonly prescribed antiemetics during pregnancy are pyridoxine and doxylamine (Diclegis, Bonjesta), ondansetron (Zofran), and promethazine (Phenergan). When to take an antiemetic is included in the patient education provided by the nurse.

Heartburn and GERD

Heartburn, also known as dyspepsia, is due to the increase in progesterone. This hormone supports the pregnancy and also causes relaxation of the cardiac sphincter and slows the emptying of the stomach. Heartburn is experienced most often in the second half of pregnancy and increases in severity in the final weeks because of the enlarged uterus. Heartburn can evolve into gastroesophageal reflux disease (GERD).

Heartburn can be relieved by remaining upright after eating and not eating for up to 2 hours before lying down to sleep. Heartburn can be lessened by not wearing tight clothes around the waist and by eating slowly, eating smaller portions, and eating foods lower in fat and spices. Some pregnant persons find that drinking a glass of milk decreases the burning sensation of heartburn, and some find that drinking an entire glass of water aggravates heartburn.

Pharmacologic measures to treat heartburn are antacid tablets containing calcium or those containing a combination of magnesium and aluminum. Antacids should be taken with meals or immediately after a meal for best effectiveness. Antacids should not be taken with iron supplements because the absorption of iron is decreased. For more severe heartburn and GERD, a histamine 2 blocker, such as famotidine (Pepcid), or a proton pump inhibitor, such as omeprazole (Prilosec), can be taken at the recommendation of the health care provider. These medications can all be purchased over the counter.

Constipation

Constipation during pregnancy is caused by the decrease in gastric motility due to the increase in progesterone. The slowing of the intestines allows more nutrients and water to be absorbed to support the pregnancy and the growth and development of the fetus. The increase in water absorption results in firmer stools that are more difficult to evacuate. The calcium and iron in prenatal vitamins add to the development of hard stools as well.

Prevention of constipation is important during pregnancy. Increasing water intake to eight glasses each day and increasing dietary fiber by including cereals with bran, whole grain breads, and fresh fruits and vegetables are preventive measures for constipation. Other dietary changes to prevent constipation include decreasing the intake of refined sugars and cheese. Exercising regularly also decreases constipation. During pregnancy, exercise can be as simple as walking a mile or swimming for 30 minutes four or five times a week. Yoga routines offer another way to exercise during pregnancy.

Pharmacologic measures to treat constipation start with adding psyllium (Metamucil) to a glass of juice or water and drinking it. Stool softeners (Dulcolax, MiraLAX) add water back into the stool to ease evacuation. Stimulant laxatives, those that increase gastric motility, are not recommended during pregnancy. All these medications are available over the counter and are taken after a discussion with the health care provider.

Hemorrhoids

Hemorrhoids occurring during pregnancy are caused by a combination of the increase in progesterone and the weight of the growing uterus. Progesterone relaxes the veins in the rectum, and the weight of the uterus causes more vasodilation. Hemorrhoids are more common during pregnancy if the pregnant person is constipated or has a low fiber intake. Prevention of hemorrhoids is key. Increasing consumption of foods high in fiber and increasing water intake help to prevent hemorrhoids during pregnancy. Increase in movement by walking more and sitting less also plays a role in the prevention of hemorrhoids.

Pharmacologic treatment of hemorrhoids includes application of witch hazel, an astringent. Products with a combination of phenylephrine, glycerin, and petroleum (Preparation H), or a combination of hydrocortisone and bismuth ointment (Anusol), are also recommended. These products decrease the swelling of the rectal tissue and are also available over the counter and taken based on the recommendation of the health care provider.

Fatigue

Fatigue is caused by the increased metabolic demands the pregnancy places on the pregnant person’s body and the production of progesterone and relaxin. Fatigue tends to occur with more frequency during the early weeks and the final weeks of the pregnancy. The early weeks are the period of most rapid growth of the fetus and uterus. In the final weeks, fatigue is the result of difficulty sleeping and the physiologic adaptations of the body to pregnancy.

Dizziness and Syncope

Occasional dizziness is expected during pregnancy and is linked to vasodilation of the blood vessels resulting from the decrease in peripheral vascular resistance caused by the increase in progesterone and relaxin hormones. This process can cause a drop in blood pressure or orthostatic hypotension. Dizziness can be prevented by staying hydrated, rising from bed slowly, and not making any sudden moves. Dizziness can also occur with low blood glucose, so instructing a patient to eat at regular times and to have a snack if needed will prevent a drop in the blood glucose level. A third cause of dizziness is anemia. Taking prenatal vitamins and consuming foods high in iron are important points for the nurse to include in the education of the pregnant person.

Syncope can also occur owing to vasodilation, low blood glucose levels, and anemia. Staying hydrated, eating at regular intervals, and having adequate intake of iron-rich foods often prevent both dizziness and syncope. Syncope can also be linked to impaired cardiac function. Once the pregnant person has been evaluated for adequate hydration, adequate food intake, and anemia, the nurse needs to assess the patient for a possible cardiac problem, such as transient tachycardia of pregnancy or preexisting cardiac disease.

Vena Cava Syndrome

The enlarging uterus places pressure on the vena cava starting around 28 weeks of gestation. This pressure can cause vena cava syndrome, which involves the pregnant person feeling dizzy, weak, and sometimes nauseated when lying flat on their back. The pressure decreases blood flow back to the heart (Figure 10.10). It is important for the nurse to instruct the pregnant person to lie down in a lateral position rather than flat on their back once they reach 28 weeks of gestation.

Figure 10.10 Vena Cava Syndrome Pregnant persons should avoid lying flat on their back to prevent vena cava syndrome, or compression of the vena cava. When the vena cava is compressed by the enlarging uterus, blood flow back to the heart is slowed, causing the pregnant person to feel dizzy, weak, and sometimes nauseated. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0)

Insomnia

Insomnia during pregnancy is due to the surge in estrogen and progesterone in early pregnancy and the common discomforts of leg cramps, back pain, and nocturia. Later in pregnancy, fetal activity may cause insomnia as the due date approaches. Developing and maintaining a daily schedule is important to sleeping well. Not drinking any fluids 2 hours before bedtime and having a consistent bedtime also help a pregnant person to sleep better. Relaxation techniques performed while lying in bed help the pregnant person to fall asleep more easily. (See further discussion on this topic in Chapter 17 Pain Management During Labor and Birth.) Chamomile tea is often used to relax and fall asleep. Pharmacologic measures include melatonin, an over-the-counter sleep aid.

Breast Tenderness

Breast tenderness is due to the increase in estrogen during pregnancy, stimulating the milk ducts and glands to increase in both number and size. Many pregnant persons need to wear a good-fitting bra when awake and asleep to decrease breast tenderness. As the pregnancy progresses, it will be necessary to purchase new bras as the breasts enlarge.

Shortness of Breath

Shortness of breath and dyspnea are caused by a rise in progesterone, estrogen, and prostaglandin. The increase in these hormones leads to lung tissue congestion. The diaphragm rises as much as 4 cm, and the rib cage diameter expands as much as 6 cm as the enlarged uterus pushes the intestines into the rib cage. Maintaining good posture and sleeping with several pillows can assist in making breathing easier.

Lower Back Discomfort

Lower back discomfort occurs because of anatomic and physiologic changes during pregnancy. Progesterone and relaxin cause the ligaments to become more elastic, and the weight of the growing uterus causes an increase in the curvature of the spine. Education to relieve lower back discomfort includes instructions on how to perform the pelvic rock, advice to wear low-heeled shoes, and information on the use of a maternity belt (Figure 10.11).

Figure 10.11 Support during Pregnancy A pregnancy belt lifts the uterus, provides support to the lower uterus and back, and decreases lower back discomfort, urinary frequency, and vulvar edema. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0)

Urinary Frequency

The pressure of the enlarging uterus on the bladder causes urinary frequency throughout pregnancy. Although restricting caffeine intake during pregnancy to 200 mg per day is recommended (ACOG, 2020b), further limiting or omitting caffeine can decrease urinary frequency. To prevent nocturia, pregnant persons can decrease their fluid intake 2 hours before bedtime. It is important for the nurse to make sure the urinary frequency is not due to the presence of a urinary tract infection.

Itching

Itching during pregnancy has been attributed to the increased blood supply to the skin and stretching of the skin due to the growing uterus. Patient education includes taking cool baths, using unscented lotions or oils on the skin, and avoiding scratching to prevent skin breakdown. Itching can also be a sign of cholestasis or liver disease and needs to be investigated.

Headache

Headaches during pregnancy are attributed to dehydration, low blood glucose, and difficulty sleeping. Estrogen production may also play a role in the occurrence of headaches. Patient education by the nurse includes instructions to the pregnant person to keep hydrated, eat regular meals and snacks, and maintain a regular routine and bedtime. The sudden onset of a severe headache can be a medical emergency, and the nurse needs to advise the pregnant person to be evaluated immediately (Mayo Clinic, 2022).

Edema

Dependent edema is common in late pregnancy. Edema is caused by the decreased peripheral vascular resistance produced by estrogen and progesterone and the pressure of the enlarged uterus on the lower extremities. The teaching includes instructing the pregnant person to wear loose clothing, use a maternity belt, avoid prolonged standing or sitting, elevate their legs when sitting, and minimize salt intake. Compression socks or stockings can also be recommended. Edema can also be a sign of preeclampsia, especially if the edema is generalized.

Varicosities

Varicosities occur during pregnancy because of the decreased peripheral vascular resistance in the lower extremities and the pressure of the enlarged uterus on the perineum. Education includes instructing the pregnant person to avoid prolonged standing or sitting and to elevate their legs when sitting. The use of support hose or a maternity belt can also help decrease the severity of varicose veins.

Leg Cramps

Leg cramps can be due to too much or too little calcium, potassium, or magnesium in the diet. Leg cramps can be relieved by dorsiflexing the foot and massaging the affected muscle. Regular exercise and a nutritionally sound diet can prevent leg cramps.

Round Ligament Pain

The round ligaments attach the uterus to the pelvis. As the uterus grows out of the pelvis and into the abdomen, stretching of the round ligaments occurs. The stretching causes the pregnant person to feel pain in the right or left lower quadrant. Round ligament pain is most often experienced by the pregnant person between 14 and 27 weeks of gestation. Round ligament pain can be relieved by warm compresses and baths, lying on the side with knees drawn up toward the abdomen, and using a maternity belt. It is important for the nurse to determine that the cause of the pain is due to the stretching of the round ligament and not appendicitis or another medical condition.

Braxton Hicks Contractions

As discussed earlier in this chapter, Braxton Hicks contractions are spontaneous, painless uterine contractions that occur throughout the pregnancy. Braxton Hicks contractions normally have no effect on the cervix until the final weeks of the pregnancy when the progesterone levels drop and the oxytocin level increases. Dehydration can increase the frequency and intensity of Braxton Hicks contractions, especially in the final weeks of the pregnancy. Maintaining an adequate fluid intake can decrease the discomfort and frequency of Braxton Hicks contractions. A maternity belt can help support the uterus and lift the fetus in the lower uterine segment, decreasing the discomfort and frequency of the Braxton Hicks contractions. Table 10.9 summarizes the common discomforts of pregnancy, their causes, and relief measures.

Hygiene

Hygiene self-care includes bathing practices, handwashing, and dental care. Bathing removes the buildup of oils, bacteria, and dirt on the body, decreasing the risk of disease. It is important for the nurse to include perineal cleansing when discussing bathing practices because of the increase in cervical and vaginal secretions during pregnancy. Frequent handwashing and cleaning under the fingernails by the pregnant person prevent illness caused by the microorganisms on multiple surfaces touched every day.

Pregnant persons should also be cautioned not to use hot tubs, saunas, or tanning beds during pregnancy. The heat generated by these products raises the pregnant person’s temperature and the fetal heart rate. The vasodilation of the blood vessels in the skin (as a response to the increase in temperature) pulls blood away from the uterus and can cause orthostatic hypotension upon standing after using these devices.

Pregnancy changes the amount of saliva and increases the vascularity of the gums. These two events place the pregnant person at risk for gingivitis, dental caries, and loss of teeth. Oral hygiene with a soft-bristled toothbrush after each meal helps to prevent the buildup of bacteria and bleeding gums. Visits with a dental hygienist for routine teeth cleaning are encouraged during pregnancy. If x-rays need to be taken, the pregnant person should wear a protective apron to shield the abdomen.

Oral hygiene also decreases the risk for periodontitis, which is associated with preterm birth and low birth weight (Uwambaye et al., 2021). The symptoms of periodontitis include bleeding gums, loose teeth, and abscess formation. The nurse can assess the mouth, gums, and teeth and refer the pregnant person to dental services before periodontitis occurs.

Clothing

Self-care related to clothing includes wearing clothes that are not constrictive to the growing uterus. This includes girdles and other shapewear. Education also includes the avoidance of knee-high stockings or socks that are tight at the top. These stockings or socks can impede circulation, increasing the risk of DVT in the pregnant person. Education also includes wearing shoes with low heels to decrease the incidence of lower back ache and risk for falls.

Exercise

Exercise decreases joint discomforts, increases endorphins to decrease fatigue, helps to prevent excessive weight gain, and improves cardiac health. All these positive attributes of exercise improve the health of the pregnant person and have a positive effect on the growth and development of the fetus. Exercise also improves posture and muscle tone and helps promote sleep and rest. When providing education on exercise during pregnancy, the nurse should base the discussion on the pregnant person’s current exercise routine. The current recommendation is a minimum of 30 to 60 minutes of exercise, three or four times per week (ACOG, 2020a).

Sleep and Rest

Balancing sleep and rest with work, household expectations, and exercise promotes self-care. During sleep, the body repairs itself and grows. During pregnancy, sleep also promotes fetal growth and development. Education for self-care involving rest and sleep includes the establishment of a consistent bedtime routine and bedtime. Consistency places the body on a schedule, making it easier to fall asleep. Limiting fluid intake for 2 hours prior to going to bed decreases nocturia and prevents interrupted sleep.

Sexual Activity and Intimacy

Sexual activity during pregnancy can remain normal for couples during an uncomplicated pregnancy (Alizadeh et al., 2021). The physiologic changes and psychosocial adaptations that occur during pregnancy may consciously and unconsciously alter the pregnant person’s interest in sexual activity and intimacy. Sexual activity is not restricted during pregnancy except in cases of vaginal bleeding, placenta previa, rupture of membranes, and preterm contractions. Intimacy involves actions and communication between the pregnant person and their support person. This can also be a hug, watching a movie together, giving gifts, or just talking.

Employment

Employment may require the pregnant person to commute or to work from home. Some pregnant persons provide full-time care for members of the immediate or extended family. The family members may be siblings of the fetus, related children or children living in the neighborhood, or adults. Pregnancy places a few limitations on job requirements. These limitations include

• no heavy lifting, specifically no more than 25 pounds after 28 weeks of gestation,
• avoiding exposure to teratogens, such as chemical fumes and tobacco products, and
• taking scheduled breaks.

Table 10.10 summarizes the self-care practices and prenatal education topics presented in this section of the chapter.