Essentials of Maternity, Newborn, and Women's Health Nursing [4 ed.] 1451193998, 9781451193992

Table of contents :
Title Page
Copyright
Dedication
About the Author
Reviewers
Preface
Contents
Contents in Brief
UNIT ONE: INTRODUCTION TO MATERNITY, NEWBORN, AND WOMEN’S NURSING
CHAPTER 1 Perspectives on Maternal, Newborn, and Women’s Health Care
Introduction
Evolution of Maternal and Newborn Nursing
Historical Perspective
Current Trends
Core Concepts of Maternal, Newborn, and Women’s Health Nursing
Family-Centered Care
Evidence-Based Care
Case-Managed Care
Health Status Goals
Healthy People 2020
Mortality
Morbidity
Factors Affecting Maternal, Newborn, and Women’s Health
Family
Genetics
Society
Culture
Health Care Cost Containment
Improvements in Diagnosis and Treatments
Empowerment of Health Care Consumers
Barriers to Health Care
Finances
Transportation
Language and Culture
Low Health Literacy
Health Care Delivery System
Legal and Ethical Issues in Maternal, Newborn, and Women’s Health Care
Abortion
Substance Abuse
Intrauterine Therapy
Maternal–Fetal Conflict
Stem Cell Research
Umbilical Cord Blood Banking
Informed Consent
Confidentiality
Implications for Nurses
CHAPTER 2 Family-Centered Community-Based Care
Introduction
Family-Centered Care
Community-Based Care
Community Health Nursing
Community-Based Nursing
Cultural Issues in Community-Based Nursing
Use of Complementary and Alternative Medicine
Community-Based Nursing Care Settings
Prenatal Care
Labor and Birth Care
Postpartum and Newborn Care
Women’s Health Care
Roles and Functions of the Community-Based Nurse
Communicator
Direct Care Provider
Educator
Discharge Planner and Case Manager
Advocate and Resource Manager
UNIT TWO: WOMEN’S HEALTH THROUGHOUT THE LIFESPAN
CHAPTER 3 Anatomy and Physiology of the Reproductive Systems
Introduction
Female Reproductive Anatomy and Physiology
External Female Reproductive Organs
Internal Female Reproductive Organs
Breasts
Female Sexual Response
The Female Reproductive Cycle
Ovarian Cycle
Endometrial (Uterine) Cycle
Menstruation
Perimenopause
Menopause
Male Reproductive Anatomy and Physiology
External Male Reproductive Organs
Internal Male Reproductive Organs
Male Sexual Response
CHAPTER 4 Common Reproductive Issues
Introduction
Menstrual Disorders
Amenorrhea
Dysmenorrhea
Abnormal Uterine Bleeding
Premenstrual Syndrome
Endometriosis
Infertility
Cultural Considerations
Etiology and Risk Factors
Therapeutic Management
Nursing Assessment
Nursing Management
Contraception
Types of Contraceptive Methods
Nursing Management of the Woman Choosing a Contraceptive Method
Nursing Assessment
Nursing Diagnoses
Nursing Interventions
Abortion
Surgical Abortion
Medical Abortion
Menopausal Transition
Therapeutic Management
Nursing Assessment
Nursing Management
CHAPTER 5 Sexually Transmitted Infections
Introduction
Cultural and Psychological Components of Sexually Transmitted Infections
Sexually Transmitted Infections and Adolescents
Risk Factors
Healthy People 2020 Objective
Nursing Assessment
Nursing Management
Infections Characterized by Vaginal Discharge
Genital/Vulvovaginal Candidiasis
Trichomoniasis
Bacterial Vaginosis
Infections Characterized by Cervicitis
Chlamydia
Gonorrhea
Infections Characterized by Genital Ulcers
Genital Herpes Simplex
Syphilis
Pelvic Inflammatory Disease
Vaccine-Preventable STIs
Human Papillomavirus
Hepatitis A and B
Hepatitis C
Zika Virus Disease
Ectoparasitic Infections
Human Immunodeficiency Virus
HIV and Adolescents
Clinical Manifestations
Diagnosis
Therapeutic Management
Nursing Management
Providing Education About Drug Therapy
Preventing HIV Infection
Providing Care During Pregnancy and Childbirth
Providing Appropriate Referrals
Preventing Sexually Transmitted Infections
Behavior Modification
Contraception
CHAPTER 6 Disorders of the Breasts
Introduction
Benign Breast Disorders
Fibrocystic Breast Changes
Fibroadenomas
Mastitis
Malignant Breast Disorder
Pathophysiology
Staging of Breast Cancer
Risk Factors
Diagnosis
Therapeutic Management
Breast Cancer Screening
Nutrition
CHAPTER 7 Benign Disorders of the Female Reproductive Tract
Introduction
Pelvic Floor Disorders
Pelvic Organ Prolapse
Urinary Incontinence
Benign Growths
Polyps
Uterine Fibroids
Genital Fistulas
Bartholin’s Cysts
Ovarian Cysts
CHAPTER 8 Cancers of the Female Reproductive Tract
Introduction
Ovarian Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
Endometrial Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
Cervical Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
Vaginal Cancer
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Vulvar Cancer
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
CHAPTER 9 Violence and Abuse
Introduction
Intimate Partner Violence
Incidence
Background
Characteristics of Intimate Partner Violence
Types of Abuse
Myths and Facts About Intimate Partner Violence
Abuse Profiles
Violence Against Pregnant Women
Violence Against Older Women
Nursing Management of Intimate Partner Violence Victims
Sexual Violence
Characteristics of Assailants
Sexual Abuse
Incest
Rape
Female Genital Cutting
Human Trafficking
Summary
UNIT THREE: PREGNANCY
CHAPTER 10 Fetal Development and Genetics
Introduction
Fetal Development
Preembryonic Stage
Embryonic Stage
Fetal Stage
Fetal Circulation
Genetics
Advances in Genetics and Genetic Technology
Inheritance
Patterns of Inheritance for Genetic Disorders
Chromosomal Abnormalities
Genetic Evaluation and Counseling
Nursing Roles and Responsibilities
CHAPTER 11 Maternal Adaptation During Pregnancy
Introduction
Signs and Symptoms of Pregnancy
Subjective (Presumptive) Signs
Objective (Probable) Signs
Positive Signs
Physiologic Adaptations During Pregnancy
Reproductive System Adaptations
General Body System Adaptations
Changing Nutritional Needs of Pregnancy
Nutritional Requirements During Pregnancy
Gluten-free Diet During Pregnancy
Maternal Weight Gain
Nutrition Promotion
Special Nutritional Considerations
Psychosocial Adaptations During Pregnancy
Maternal Emotional Responses
Becoming a Mother
Pregnancy and Sexuality
Pregnancy and the Partner
Pregnancy and Siblings
CHAPTER 12 Nursing Management During Pregnancy
Introduction
Preconception Care
Risk Factors for Adverse Pregnancy Outcomes
Nursing Management
The First Prenatal Visit
Comprehensive Health History
Physical Examination
Laboratory Tests
Follow-up Visits
Follow-Up Visit Intervals and Assessments
Fundal Height Measurement
Fetal Movement Determination
Fetal Heart Rate Measurement
Teaching About the Danger Signs of Pregnancy
Assessment of Fetal Well-Being
Ultrasonography
Doppler Flow Studies
Alpha-Fetoprotein Analysis
Marker Screening Tests
Nuchal Translucency Screening
Amniocentesis
Chorionic Villus Sampling
Nonstress Test
Biophysical Profile
Nursing Management for the Common Discomforts of Pregnancy
First-Trimester Discomforts
Second-Trimester Discomforts
Third-Trimester Discomforts
Nursing Management to Promote Self-Care
Personal Hygiene
Clothing
Exercise
Sleep and Rest
Sexual Activity and Sexuality
Employment
Travel
Immunizations and Medications
Nursing Management to Prepare the Woman and Her Partner for Labor, Birth, and Parenthood
Childbirth Education Classes
Nursing Management and Childbirth Education
Options for Birth Settings and Care Providers
Preparation for Breast-Feeding or Bottle-Feeding
Final Preparation for Labor and Birth
UNIT FOUR: LABOR AND BIRTH
CHAPTER 13 Labor and Birth Process
Introduction
Initiation of Labor
Premonitory Signs of Labor
Cervical Changes
Lightening
Increased Energy Level
Bloody Show
Braxton Hicks Contractions
Spontaneous Rupture of Membranes
True Versus False Labor
Factors Affecting the Labor Process
Passageway
Passenger
Powers
Position (Maternal)
Psychological Response
Philosophy
Partners
Patience
Patient (Client) Preparation: Prenatal Education
Pain Management
Physiologic Responses to Labor
Maternal Responses
Fetal Responses
Stages of Labor
First Stage
Second Stage
Third Stage
Fourth Stage
CHAPTER 14 Nursing Management During Labor and Birth
Introduction
Maternal Assessment During Labor and Birth
Vaginal Examination
Assessing Uterine Contractions
Performing Leopold’s Maneuvers
Fetal Assessment During Labor and Birth
Analysis of Amniotic Fluid
Analysis of the FHR
Other Fetal Assessment Methods
Promoting Comfort and Providing Pain Management During Labor
Nonpharmacologic Measures
Pharmacologic Measures
Nursing Care During Labor and Birth
Nursing Management During the First Stage of Labor
Nursing Management During the Second Stage of Labor
Nursing Management During the Third Stage of Labor
Nursing Management During the Fourth Stage of Labor
UNIT FIVE: POSTPARTUM PERIOD
CHAPTER 15 Postpartum Adaptations
Introduction
Maternal Physiologic Adaptations
Reproductive System Adaptations
Cardiovascular System Adaptations
Urinary System Adaptations
Gastrointestinal System Adaptations
Musculoskeletal System Adaptations
Integumentary System Adaptations
Respiratory System Adaptations
Endocrine System Adaptations
Weight Loss After Childbirth
Cultural Considerations for the Postpartum Period
Balance of Hot and Cold
Postpartum Cultural Beliefs
Psychological Adaptations
Parental Attachment Behaviors
Maternal Psychological Adaptations
Partner Psychological Adaptations
CHAPTER 16 Nursing Management During the Postpartum Period
Introduction
Social Support and Cultural Considerations
Nursing Assessment in the Postpartum Period
Vital Signs Assessment
Physical Examination
Psychosocial Assessment
Nursing Interventions
Providing Optimal Cultural Care
Promoting Comfort
Assisting With Elimination
Promoting Activity, Rest, and Exercise
Preventing Stress Incontinence
Assisting With Self-Care Measures
Ensuring Safety
Counseling About Sexuality and Contraception
Promoting Maternal Nutrition
Supporting the Woman’s Choice of Infant Feeding Method
Teaching About Breast Care
Promoting Family Adjustment and Well-Being
Preparing for Discharge
UNIT SIX: THE NEWBORN
CHAPTER 17 Newborn Transitioning
Introduction
Physiologic Transitioning
Cardiovascular System Adaptations
Respiratory System Adaptations
Body Temperature Regulation
Hepatic System Function
Gastrointestinal System Adaptations
Renal System Changes
Immune System Adaptations
Integumentary System Adaptations
Neurologic System Adaptations
Behavioral Adaptations
Behavioral Patterns
Behavioral Responses
CHAPTER 18 Nursing Management of the Newborn
Introduction
Nursing Management During the Immediate Newborn Period
Assessment
Nursing Interventions
Nursing Management During the Early Newborn Period
Assessment
Nursing Interventions
UNIT SEVEN: CHILDBEARING AT RISK
CHAPTER 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications
Introduction
Bleeding During Pregnancy
Spontaneous Abortion
Ectopic Pregnancy
Gestational Trophoblastic Disease
Cervical Insufficiency
Placenta Previa
Abruptio Placentae
Placenta Accreta
Hyperemesis Gravidarum
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Hypertensive Disorders of Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia and Eclampsia
Hellp Syndrome
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Gestational Diabetes
Blood Incompatibility
Pathophysiology
Nursing Assessment
Nursing Management
Amniotic Fluid Imbalances
Polyhydramnios
Oligohydramnios
Multiple Gestation
Therapeutic Management
Nursing Assessment
Nursing Management
Premature Rupture of Membranes
Therapeutic Management
Nursing Assessment
Nursing Management
CHAPTER 20 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations
Introduction
Diabetes Mellitus
Pathophysiology
Screening
Therapeutic Management
Nursing Assessment
Nursing Management
Cardiovascular Disorders
Congenital and Acquired Heart Disease
Hypertension in Pregnancy
Chronic Hypertension
Respiratory Conditions
Asthma
Tuberculosis
Hematologic Conditions
Iron-Deficiency Anemia
Thalassemia
Sickle Cell Anemia
Autoimmune Disorders
Systemic Lupus Erythematosus
Multiple Sclerosis
Rheumatoid Arthritis
Infections
Cytomegalovirus
Rubella
Herpes Simplex Virus
Hepatitis B Virus
Varicella Zoster Virus
Parvovirus B19
Group B Streptococcus
Toxoplasmosis
Women Who Are HIV Positive
Vulnerable Populations
Pregnant Adolescent
The Advanced Maternal Age Woman
The Obese Pregnant Woman
The Pregnant Woman and Substance Abuse
CHAPTER 21 Nursing Management of Labor and Birth at Risk
Introduction
Dystocia
Problems with the Powers
Problems with the Passenger
Problems with the Passageway
Problems with the Psyche
Nursing Assessment
Alternative/Nontraditional Families
Preterm Labor
Therapeutic Management
Nursing Assessment
Nursing Management
Post-Term Pregnancy
Nursing Assessment
Nursing Management
Women Requiring Labor Induction and Augmentation
Therapeutic Management
Nursing Assessment
Nursing Management
Vaginal Birth After Cesarean
Intrauterine Fetal Demise
Nursing Assessment
Nursing Management
Women Experiencing an Obstetric Emergency
Umbilical Cord Prolapse
Placenta Previa
Placental Abruption
Uterine Rupture
Amniotic Fluid Embolism
Women Requiring Birth-Related Procedures
Amnioinfusion
Forceps- or Vacuum-Assisted Birth
Cesarean Birth
CHAPTER 22 Nursing Management of the Postpartum Woman at Risk
Introduction
Postpartum Hemorrhage
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
Venous Thromboembolic Conditions
Pathophysiology
Nursing Assessment
Nursing Management
Postpartum Infection
Metritis
Surgical Site Infections
Urinary Tract Infections
Mastitis
Postpartum Affective Disorders
Postpartum Blues
Postpartum Depression
Postpartum Psychosis
UNIT EIGHT: THE NEWBORN AT RISK
CHAPTER 23 Nursing Care of the Newborn with Special Needs
Birth-Weight Variations
Small-for-Gestational-Age Newborns
Large-for-Gestational-Age Newborns
Gestational Age Variations
Preterm Newborn
Late Preterm (“Near Term”) Newborn
Post-Term Newborn
Dealing With Perinatal Loss
CHAPTER 24 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions
Introduction
Acquired Disorders
Perinatal Asphyxia
Transient Tachypnea of the Newborn
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
Persistent Pulmonary Hypertension of the Newborn
Bronchopulmonary Dysplasia/Chronic Lung Disease
Retinopathy of Prematurity
Periventricular–Intraventricular Hemorrhage
Necrotizing Enterocolitis
Infant of a Diabetic Mother
Birth Trauma
Newborns of Substance-Abusing Mothers
Hyperbilirubinemia
Neonatal Sepsis
Congenital Conditions
Congenital Heart Disease
Neural Tube Defects
Microcephaly
Hydrocephalus
Choanal Atresia
Congenital Diaphragmatic Hernia
Cleft Lip and Palate
Esophageal Atresia and Tracheoesophageal Fistula
Omphalocele and Gastroschisis
Imperforate Anus
Hypospadias
Epispadias
Bladder Exstrophy
Congenital Clubfoot
Developmental Dysplasia of the Hip
Inborn Errors of Metabolism
APPENDIX A Standard Laboratory Values
APPENDIX B Clinical Paths
APPENDIX C Cervical Dilation Chart
APPENDIX D Weight Conversion Charts
APPENDIX E Breast-Feeding and Medication Use
Index

Citation preview

ESSENTIALS of Maternity, Newborn, AND Women’s Health Nursing FOURTH EDITION

Susan Scott Ricci, ARNP, MSN, M.Ed., CNE Nursing Faculty University of Central Florida Orlando, Florida Former Nursing Program Director and Faculty Lake Sumter State College Leesburg, Florida

Acquisitions Editor: Natasha McIntyre Product Development Editor: Annette Ferran Editorial Assistant: Dan Reilly Design Coordinator: Terry Mallon Illustration Coordinator: Jennifer Clements Production Project Manager: Priscilla Crater Manufacturing Coordinator: Karin Duffield Prepress Vendor: Aptara, Inc. 4th Edition Copyright © 2017 Wolters Kluwer. Copyright © 2013, 2009, 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the abovementioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our web site at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S. Virgin Islands. Library of Congress Cataloging-in-Publication Data Names: Ricci, Susan Scott, author. Title: Essentials of maternity, newborn & women’s health nursing / Susan Scott Ricci. Other titles: Essentials of maternity, newborn, and women’s health nursing Description: Fourth edition. | Philadelphia : Wolters Kluwer, [2017] | Includes bibliographical references and index.

Identifiers: LCCN 2016021183 | ISBN 9781451193992 Subjects: | MESH: Maternal-Child Nursing | Obstetric Nursing | Pregnancy Complications–nursing Classification: LCC RG951 | NLM WY 157.3 | DDC 618.2/0231–dc23 LC record available at https://lccn.loc.gov/2016021183 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com

This book is lovingly dedicated to my husband Glenn, for his unfailing patience, encouragement,—and whose support and sense of humor make anything possible. And also to my children, Brian and Jennifer, and my grandchildren— Alyssa, Leyton, Peyton, Wyatt, Michael, Rylan, and Brody—who continue to inspire me throughout my life. You make it all worthwhile. Susan Scott Ricci

About the Author

Susan Scott Ricci earned a diploma in nursing from the Washington Hospital Center School of Nursing, with a BSN and MSN, from Catholic University of America located in Washington, D.C., a M.Ed. in Counseling from the University of Southern Mississippi. She is licensed as a Women’s Health Nurse Practitioner (ARNP) from the University of Florida. She recently acquired her national certification as a Certified Nurse Educator (CNE). She has worked in numerous women’s health care settings including labor and birth, postpartum, prenatal, and family planning ambulatory care clinics. Susan is a women’s health care nurse practitioner, who has spent 30+ years in practice and in nursing education teaching in LPN, ADN, and BSN programs. She is involved in several professional nursing organizations and holds memberships in Sigma Theta Tau International Honor Society of Nursing, National Association of OB/GYN Nurses, Who’s Who in Professional Nursing, American Nurses Association, and the Florida Council of Maternal–Child Nurses. With Susan Scott Ricci’s wealth of practical and educational experience, it is essential to concentrate on evidence-based nursing practice and reduce the amount of “nice to know” information that is presented to students. As an educator, she recognized the tendency for nursing educators to want to “cover the world” when teaching, rather than focusing on the facts that students need to know to practice nursing safely. With this mission in mind, Susan has directed

her energy to the birth of these essential facts in this textbook. She recognizes that instructional time is shrinking as the world of health care is expanding exponentially. Therefore, with the valuable instructional time allotted, she has recognized the urgent need to present pertinent facts as concisely as possible to promote application of knowledge within nursing practice.

Reviewers Vicki Aaberg, PhD, RN Nursing Instructor Seattle Pacific University Seattle, Washington Robin Adams-Weber, DNP, RN, WHNPBC Associate Professor of Nursing Women’s Health Nurse Practitioner Malone University Canton, Ohio Nancy Ahern, PhD, RN Associate Professor of Nursing California State University Fullerton, California Louise Aurilio, PhD, RN-BC, NE-BC Associate Professor Youngstown State University Youngstown, Ohio Kathleen Beebe, PhD, RN Associate Professor Dominican University of California San Francisco, California Tammy Bryant, MSN, RN Program Director/Nursing Instructor Southern Regional Technical College Thomasville, Georgia Stephanie Butkus

Associate Professor Kettering College of Medical Arts Dayton, Ohio Amanda Campbell, PhD, RN Associate Professor Tyler Junior College Tyler, Texas Yasmin Cavenagh, MSN, MPH, RN Instructor Resurrection University Chicago, Illinois Tracy Colburn, MSN, BSN, RN, CEFM Assistant Professor Lewis and Clark Community College Godfrey, Illinois Denise Condra, MSN, RN, FNP-C Associate Professor Mount San Antonio College Walnut, California Patricia Davidson, MSN, RN Clinical Associate Professor University of Texas Health Science Center San Antonio, Texas Tamara Dennis, PhD, RNC Associate Professor of Nursing Abraham Baldwin Agricultural College Tifton, Georgia Barbara Derwinski-Robinson, MSN-RNC-WH-BC Associate Professor Montana State University Billings, Montana

Susan Dougherty, DNO, MS, RNC, WHNP Assistant Professor Augusta University Augusta, Georgia Judith Drumm, RN, DNSc Associate Professor Palm Beach Atlantic University West Palm Beach, Florida Brooke Flinders, MSN, RN, CNM Assistant Professor Miami University Hamilton Miami, Florida Helen Gordon, MS, RN, CNM Assistant Professor Duke University Durham, North Carolina Susan Hall, MSN, RNC Nursing Instructor Winston-Salem State University Winston-Salem, North Carolina Elva Hammarstrand, RN, BScN, MN Nursing Instructor Red Deer College Winnipeg, Manitoba, Canada Marie Hanna, RN, MS, WHNP-C Professor of Nursing Suffolk County Community College Selden, New York Christina Harkins, MSN, RN Assistant Professor Lasalle University

Philadelphia, Pennsylvania Sally Hartman, RNC, MSN, IBCLC, FACCE Clinical Assistant Professor Indiana Purdue University Fort Wayne, Indiana Mary Jane Hopkins, ARNP, BSN, MSN Nursing Instructor Indian River Community College Fort Pierce, Florida Carmen Kiraly, RN, MS, C-WHNP Assistant Professor Suffolk County Community College Brentwood, New York Joan Kuhnly, MS, RN, IBCLC Nursing Instructor University of Connecticut Storrs, Connecticut Christine Kuoni, MSN Assistant Professor San Antonio College San Antonio, Texas Diwana Lowe, MSN, RNC-OB Associate Professor - Retired Georgia Perimeter College Georgia State University Atlanta, Georgia Maria Marconi, RN, MS Assistant Professor University of Rochester Rochester, New York

Lucy Martinez-Schallmoser, PhD, RNC Assistant Professor Loyola University Chicago, Illinois Tammy McInerney, DNP, RN, NNPBC, CPNP Assistant Professor Delta College University Center, Michigan Anne Mitchell, PhD, RN, CNM Assistant Professor Oakland University Rochester, Michigan Anna Morris, MSN, RN Assistant Professor Northwestern State University Natchitoches, Louisiana Gretchen A. Nelson, BSN, MN, RNFA, FNP-c Nursing Faculty Fresno City College Fresno, California Valerie O’Dell, DNP, RN, CNE Associate Professor/MSN Program Director Youngstown State University Youngstown, Ohio Ann Marie Paraszczuk, EdD, MS, RNC Professor Molloy College Rockville Center, New York Cynthia Payne, BSN, MS, NP-BC, CNM Assistant Professor Georgia State at Perimeter College

Atlanta, Georgia Audrey Perry, DNP, CNM, RN Faculty Nurse Midwife Reading Health School of Health Sciences West Reading, Pennsylvania Deborah A. Raines, PhD, EdS, RN, ANEF Associate Professor University at Buffalo: The State University of New York Buffalo, New York Anne Marie Rameika, MSN, FNP Associate Professor Community College of Rhode Island Newport, Rhode Island Frances Reynolds, MSN, RN Assistant Professor of Nursing Howard Community College Columbia, Maryland Margaret Riden, RN, MSN Program Director Blue Ridge Community and Technical College Martinsburg, West Virginia Aissa Yolanda Scott, MS, ARNP, CNM Nurse Educator Saint Petersburg College Pinellas Park, Florida Carol Siegmund, MSN, RN Assistant Professor of Nursing Leigh Carbon Community College Schnecksville, Pennsylvania Joyce Sizemore, MSN, RN

Professor of Nursing Collin College McKinney, Texas Lauren Stehling, MSN/Ed, APRN, FNP-BC Family Nurse Practitioner/Professional Nursing Faculty Baptist Health System School of Health Professions San Antonio, Texas Barbara Stoner, RN, MSN Nursing Faculty Arapahoe Community College Littleton, Colorado Diane Thulier, PhD, RN Assistant Professor University of Rhode Island Kingston, Rhode Island Lois Tschetter, EdD, RN, IBCLC, CNE Associate Professor South Dakota State University Brookings, South Dakota Becky Weatherly, MSN, RN Assistant Professor Touro University Henderson, Nevada Deborah Whittaker, EdD, RN, RNC-MNN Assistant Professor of Clinical Nursing DeSales University Center Valley, Pennsylvania Angela Watkins, MSN, RN Program Director Calhoun Community College Decatur, Alabama

Carol Wiggs, PhD, RN, CNM Associate Professor University of Texas Medical Branch Galveston, Texas Barbara Wilford, MSN, MBA, RN Assistant Professor Lorain County Community College Elyria, Ohio Barbara Wilson, PhD, RNC Associate Professor Arizona State University Tempe, Arizona Beth Youngblood, MSN, BSN Associate Professor Belmont University Nashville, Tennessee

Preface This textbook is designed as a practical approach to understanding the health of women in a maternity context and the health of their newborns. Women in our society are becoming empowered to make informed and responsible choices regarding their health and that of their newborns, but to do so they need the encouragement and support of nurses who care for them. This textbook focuses on the reproductive issues of women throughout the lifespan and arms the student or practicing nurse with essential information to care for women and their families and to assist them to make the right choices safely, intelligently, and with confidence. Since the health care focus of women and their families has expanded well beyond our nation’s borders, more cultural and global aspects of maternity and women’s health care have been added to this fourth edition. The United States is part of the international community, and as such nurses must understand and respect diverse cultures and their customs to truly play an important role as a global partner. Nurses care for a variety of women from many continents, thus they have to be armed with appropriate tools to meet their client’s diverse needs. Also, more evidence-based research findings have been included in this fourth edition for nurses to validate their practice and interventions.

ORGANIZATION Each chapter of this textbook reviews an important dimension of a woman’s general health throughout her life cycle and addresses risk factors, lifestyle choices that influence her well-being, appropriate interventions, and nursing education topics to preserve her health and that of her newborn. The text is divided into eight units.

Unit 1: Introduction to Maternity, Newborn, and Women’s Nursing Unit 1 helps build a foundation for the student beginning with the study of maternal–newborn and women’s health nursing by exploring contemporary issues and trends and community-based nursing.

Unit 2: Women’s Health Throughout the Life Span Unit 2 introduces the student to selected women’s health topics, including the structure and function of the reproductive system, common reproductive concerns, sexually transmitted infections, problems of the breast, and benign disorders and cancers of the female reproductive tract. This unit encourages students to assist women in maintaining their quality of life, reducing their risk of disease, and becoming active partners in their own health promotion activities and with their health care professional.

Unit 3: Pregnancy Unit 3 addresses topics related to normal pregnancy, including fetal development, genetics, and maternal adaptation to pregnancy. Nursing management during normal pregnancy is presented in a separate chapter encouraging application of basic knowledge to nursing practice. This nursing care chapter covers maternal and fetal assessment throughout pregnancy, interventions to promote self-care and minimize common discomforts, and client education.

Unit 4: Labor and Birth Unit 4 begins with a chapter on the normal labor and birth process, including maternal and fetal adaptations. This is followed by a chapter discussing the nurse’s role during normal labor and birth, which includes maternal and fetal assessment, pharmacologic and nonpharmacologic comfort measures and pain management, and specific nursing interventions during each stage of labor and birth.

Unit 5: Postpartum Period Unit 5 focuses on maternal adaptation during the normal postpartum period. Both physiologic and psychological aspects are explored. Paternal adaptation is also considered. This unit also focuses on related nursing management, including assessment of physical and emotional status, promoting comfort, assisting with elimination, counseling about sexuality and contraception, promoting nutrition, promoting family adaptation, and discharge planning.

Unit 6: The Newborn Unit 6 covers physiologic and behavioral adaptations of the normal newborn. It also delves into nursing management of the normal newborn, including immediate assessment and specific interventions as well as ongoing assessment, physical examination, and specific interventions during the early newborn period.

Unit 7: Childbearing at Risk Unit 7 shifts the focus to at-risk pregnancy, childbirth, and postpartum care. Preexisting conditions of the woman, pregnancy-related complications, at-risk labor, emergencies associated with labor and birth, and medical conditions and complications affecting the postpartum woman are covered. Treatment and nursing management are presented for each medical condition. This organization allows the student to build on a solid foundation of normal material when studying the at-risk content.

Unit 8: The Newborn at Risk Unit 8 continues to focus on at-risk content. Issues of the newborn with birth weight variations, gestational age variations, congenital conditions, and acquired disorders are explored. Treatment and nursing management are presented for each medical condition. This organization helps cement the student’s understanding of the material.

RECURRING FEATURES To provide the instructor and student with an exciting and user-friendly text, a number of recurring features have been developed.

Key Terms A list of terms that are considered essential to the chapter’s understanding is presented at the beginning of each chapter. Each key term appears in boldface, with the definition included in the text. Key terms may also be accessed on .

Learning Objectives Learning objectives included at the beginning of each chapter guide the student in understanding what is important and why, allowing him or her to prioritize information for learning. These valuable learning tools also provide opportunities for self-testing or instructor evaluation of student knowledge and ability.

WOW Each chapter opens with inspiring Words of Wisdom, which offer helpful, timely, or interesting thoughts. These WOW statements set the stage for each chapter and give the student valuable insight into nursing care of women and newborns.

Case Studies Real-life scenarios present relevant maternity, newborn, and women’s health information that is intended to perfect the student’s caregiving skills. Questions about the scenario provide an opportunity for the student to critically evaluate the appropriate course of action.

Evidence-Based Practice The consistent promotion of evidence-based practice is a key feature of the text. Throughout the chapters, pivotal questions addressed by current research have been incorporated into Evidence-Based Practice boxes, which cite studies relevant to the chapter content.

Healthy People 2020 Throughout the textbook, relevant Healthy People 2020 objectives are outlined in box format. The nursing implications or guidance provided in the box serves as a road map for improving the health of women, mothers, and newborns.

Teaching Guidelines An important tool for achieving health promotion and disease prevention is health education. Throughout the textbook, Teaching Guidelines raise awareness, provide timely and accurate information, and are designed to ensure the student’s preparation for educating women about various issues.

Drug Guides Drug guide tables summarize information about commonly used medications. The actions, indications, and significant nursing implications presented assist the student in providing optimum care to women and their newborns.

Common Laboratory and Diagnostic Tests Common Laboratory and Diagnostic Test tables in many of the chapters provide the student with a general understanding of how a broad range of disorders is diagnosed. Rather than reading the information repeatedly throughout the narrative, the student is then able to refer to the table as needed.

Common Medical Treatments Common Medical Treatment tables in many of the nursing management chapters provide the student with a broad awareness of how a common group of disorders is treated either medically or surgically. The tables serve as a reference point for common medical treatments.

Nursing Care Plans Nursing Care Plans provide concrete examples of each step of the nursing process and are provided in numerous chapters.1 Found within the nursing process overview section of the chapter, the Nursing Care Plans summarize issue- or system-related content and outline a guide for delivering care.

Comparison Charts These charts compare two or more disorders or other easily confused concepts. They serve to provide an explanation that clarifies the concepts for the student.

Nursing Procedures Step-by-step Nursing Procedures are presented in a clear, concise format to facilitate competent performance of relevant procedures as well as to clarify any variations when appropriate.

Icons Watch and Learn A special icon throughout the book directs students to free video clips located on that highlight growth and development, communicating with children, and providing nursing care to the child in the hospital. Concepts in Action Animations These unique animations, also located on thePoint, bring physiologic and pathophysiologic concepts to life and enhance student comprehension.

Consider This! In every chapter, the student is asked to Consider This! These first-person narratives engage the student in real-life scenarios experienced by their patients. The personal accounts evoke empathy and help the student to perfect caregiving skills. Each box ends with an opportunity for further contemplation, encouraging the student to think critically about the scenario.

Take Note! The Take Note! feature draws the student’s attention to points of critical emphasis throughout the chapter. This feature is often used to stress lifethreatening or otherwise vitally important information.

Tables, Boxes, Illustrations, and Photographs Abundant tables and boxes summarize key content throughout the book. Additionally, beautiful illustrations and photographs help the student to visualize the content. These features allow the student to quickly and easily access information.

Key Concepts At the end of each chapter, Key Concepts provide a quick review of essential chapter elements. These bulleted lists help the student focus on the important aspects of the chapter.

References and Websites References that were used in the development of the text are provided at the end of each chapter. The websites are located on thePoint. These listings enable the student to further explore topics of interest. Many online websites are provided as a means for the student to electronically explore relevant content material. These resources can be shared with women, children, and their families to enhance patient education and support.

Chapter Worksheets Chapter worksheets at the end of each chapter assist the student in reviewing essential concepts. Chapter worksheets include: • Multiple-Choice Questions—These review questions are written to test the student’s ability to apply chapter material. Questions cover maternal–newborn and women’s health content that the student might encounter on the national licensing exam (NCLEX). • Critical Thinking Exercises—These exercises challenge the student to incorporate new knowledge with previously learned concepts and reach a satisfactory conclusion. They encourage the student to think critically, problem-solve, and consider his or her own perspective on given topics. • Study Activities—These interactive activities promote student participation in the learning process. This section encourages increased interaction/learning via clinical, online, and community activities.

Teaching–Learning Package Instructor’s Resources Tools to assist you with teaching your course are available upon adoption of this text on at http://thePoint.lww.com/Ricci3e. • An E-Book on gives you access to the book’s full text and images online. • A Test Generator lets you put together exclusive new tests from a bank containing over 800 questions (twice as many as last edition) to help you in assessing your students’ understanding of the material. Test questions link to chapter learning objectives. • PowerPoint presentations with Guided Lecture Notes provide an easy way for you to integrate the textbook with your students’ classroom experience, either via slide shows or handouts. Multiple-choice and true/false questions are integrated into the presentations to promote class participation. • An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course. • Case Studies with related questions (and suggested answers) give students an opportunity to apply their knowledge to a client case similar to one they might encounter in practice. • Pre-Lecture Quizzes (and answers) are quick, knowledge-based assessments that allow you to check students’ reading. • Discussion Topics (and suggested answers) can be used as conversation starters or in online discussion boards. • Assignments (and suggested answers) include group, written, clinical, and Web assignments. • Sample Syllabi provide guidance for structuring your pediatric nursing courses and are provided for four different course lengths: 4, 6, 8, and 10 weeks. • Journal Articles, updated for the new edition, offer access to current research available in Lippincott Williams & Wilkins journals. Contact your sales representative or check out LWW.com/Nursing for more details and ordering information. Student Resources An exciting set of free resources is available to help students review material and become even more familiar with vital concepts. Students can access all these

resources on thePoint using the codes printed in the front of their textbooks. • NCLEX-Style Review Questions for each chapter help students review important concepts and practice for NCLEX. Over 700 questions are included, more than twice as many as last edition! • Multimedia Resources appeal to a variety of learning styles. Icons in the text direct readers to relevant videos and animations: • Watch and Learn Videos A special icon throughout the book directs students to free video clips located on thePoint that highlight growth and development, communicating with children, and providing nursing care to the child in the hospital. • Concepts in Action Animations These unique animations, also located on , bring physiologic and pathophysiologic concepts to life and enhance student comprehension. • A Spanish–English Audio Glossary provides helpful terms and phrases for communicating with patients who speak Spanish. • Journal Articles offer access to current research available in Lippincott Williams & Wilkins journals. • And more! Susan Scott Ricci 1Nursing Process Overview contains NANDA-I approved nursing diagnoses. Material related to nursing diagnoses is from Nursing Diagnoses—Definitions and Classification 2012-2014 © 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA International. Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing.

Contents UNIT ONE

INTRODUCTION TO MATERNITY, NEWBORN, AND WOMEN’S NURSING CHAPTER 1 Perspectives on Maternal, Newborn, and Women’s Health Care Introduction Evolution of Maternal and Newborn Nursing Historical Perspective, • Current Trends Core Concepts of Maternal, Newborn, and Women’s Health Nursing Family-Centered Care, • Evidence-Based Care, • Case-Managed Care Health Status Goals Healthy People 2020, • Mortality, • Morbidity Factors Affecting Maternal, Newborn, and Women’s Health Family, • Genetics, • Society, • Culture, • Health Care Cost Containment, • Improvements in Diagnosis and Treatments, • Empowerment of Health Care Consumers Barriers to Health Care Finances, • Transportation, • Language and Culture, • Low Health Literacy, • Health Care Delivery System Legal and Ethical Issues in Maternal, Newborn, and Women’s Health Care Abortion, • Substance Abuse, • Intrauterine Therapy, • Maternal–Fetal Conflict, • Stem Cell Research, • Umbilical Cord Blood Banking, • Informed Consent, • Confidentiality Implications for Nurses

CHAPTER 2 Family-Centered Community-Based Care

Introduction Family-Centered Care Community-Based Care Community Health Nursing, • Community-Based Nursing, • Cultural Issues in Community-Based Nursing, • Use of Complementary and Alternative Medicine Community-Based Nursing Care Settings Prenatal Care, • Labor and Birth Care, • Postpartum and Newborn Care, • Women’s Health Care Roles and Functions of the Community-Based Nurse Communicator, • Direct Care Provider, • Educator, • Discharge Planner and Case Manager, • Advocate and Resource Manager

UNIT TWO

WOMEN’S HEALTH THROUGHOUT THE LIFESPAN CHAPTER 3 Anatomy and Physiology of the Reproductive Systems Introduction Female Reproductive Anatomy and Physiology External Female Reproductive Organs, • Internal Female Reproductive Organs, • Breasts, • Female Sexual Response The Female Reproductive Cycle Ovarian Cycle, • Endometrial (Uterine) Cycle, • Menstruation, • Perimenopause, • Menopause Male Reproductive Anatomy and Physiology External Male Reproductive Organs, • Internal Male Reproductive Organs, • Male Sexual Response

CHAPTER 4 Common Reproductive Issues Introduction Menstrual Disorders

Amenorrhea, • Dysmenorrhea, • Abnormal Uterine Bleeding, • Premenstrual Syndrome, • Endometriosis Infertility Cultural Considerations, • Etiology and Risk Factors, • Therapeutic Management, • Nursing Assessment, • Nursing Management Contraception Types of Contraceptive Methods, • Nursing Management of the Woman Choosing a Contraceptive Method, • Nursing Assessment, • Nursing Diagnoses, • Nursing Interventions Abortion Surgical Abortion, • Medical Abortion Menopausal Transition Therapeutic Management, • Nursing Assessment, • Nursing Management

CHAPTER 5 Sexually Transmitted Infections Introduction Cultural and Psychological Components of Sexually Transmitted Infections Sexually Transmitted Infections and Adolescents Risk Factors, • Healthy People 2020 Objective, • Nursing Assessment, • Nursing Management Infections Characterized by Vaginal Discharge Genital/Vulvovaginal Candidiasis, • Trichomoniasis, • Bacterial Vaginosis Infections Characterized by Cervicitis Chlamydia, • Gonorrhea Infections Characterized by Genital Ulcers Genital Herpes Simplex, • Syphilis, • Pelvic Inflammatory Disease Vaccine-Preventable STIs Human Papillomavirus, • Hepatitis A and B, • Hepatitis C Zika Virus Disease Ectoparasitic Infections Human Immunodeficiency Virus HIV and Adolescents, • Clinical Manifestations, • Diagnosis, • Therapeutic Management, • Nursing Management, • Providing Education About Drug Therapy, • Preventing HIV Infection, • Providing Care During Pregnancy and Childbirth, • Providing Appropriate Referrals Preventing Sexually Transmitted Infections

Behavior Modification, • Contraception

CHAPTER 6 Disorders of the Breasts Introduction Benign Breast Disorders Fibrocystic Breast Changes, • Fibroadenomas, • Mastitis Malignant Breast Disorder Pathophysiology, • Staging of Breast Cancer, • Risk Factors, • Diagnosis, • Therapeutic Management, • Breast Cancer Screening, • Nutrition

CHAPTER 7 Benign Disorders of the Female Reproductive Tract Introduction Pelvic Floor Disorders Pelvic Organ Prolapse, • Urinary Incontinence Benign Growths Polyps, • Uterine Fibroids, • Genital Fistulas, • Bartholin’s Cysts, • Ovarian Cysts

CHAPTER 8 Cancers of the Female Reproductive Tract Introduction Ovarian Cancer Pathophysiology, • Screening and Diagnosis, • Therapeutic Management, • Nursing Assessment, • Nursing Management Endometrial Cancer Pathophysiology, • Screening and Diagnosis, • Therapeutic Management, • Nursing Assessment, • Nursing Management Cervical Cancer Pathophysiology, • Screening and Diagnosis, • Therapeutic Management, • Nursing Assessment, • Nursing Management Vaginal Cancer Pathophysiology, • Therapeutic Management, • Nursing Assessment, • Nursing Management Vulvar Cancer

Pathophysiology, • Screening and Diagnosis, • Therapeutic Management, • Nursing Assessment, • Nursing Management

CHAPTER 9 Violence and Abuse Introduction Intimate Partner Violence Incidence, • Background, • Characteristics of Intimate Partner Violence, • Types of Abuse, • Myths and Facts About Intimate Partner Violence, • Abuse Profiles, • Violence Against Pregnant Women, • Violence Against Older Women, • Nursing Management of Intimate Partner Violence Victims Sexual Violence Characteristics of Assailants, • Sexual Abuse, • Incest, • Rape, • Female Genital Cutting, • Human Trafficking Summary

UNIT THREE

PREGNANCY CHAPTER 10 Fetal Development and Genetics Introduction Fetal Development Preembryonic Stage, • Embryonic Stage, • Fetal Stage, • Fetal Circulation Genetics Advances in Genetics and Genetic Technology, • Inheritance, • Patterns of Inheritance for Genetic Disorders, • Chromosomal Abnormalities, • Genetic Evaluation and Counseling Nursing Roles and Responsibilities

CHAPTER 11 Maternal Adaptation During Pregnancy Introduction Signs and Symptoms of Pregnancy Subjective (Presumptive) Signs, • Objective (Probable) Signs, • Positive Signs Physiologic Adaptations During Pregnancy

Reproductive System Adaptations, • General Body System Adaptations Changing Nutritional Needs of Pregnancy Nutritional Requirements During Pregnancy, • Gluten-free Diet During Pregnancy, • Maternal Weight Gain, • Nutrition Promotion, • Special Nutritional Considerations Psychosocial Adaptations During Pregnancy Maternal Emotional Responses, • Becoming a Mother, • Pregnancy and Sexuality, • Pregnancy and the Partner, • Pregnancy and Siblings

CHAPTER 12 Nursing Management During Pregnancy Introduction Preconception Care Risk Factors for Adverse Pregnancy Outcomes, • Nursing Management The First Prenatal Visit Comprehensive Health History, • Physical Examination, • Laboratory Tests Follow-up Visits Follow-Up Visit Intervals and Assessments, • Fundal Height Measurement, • Fetal Movement Determination, • Fetal Heart Rate Measurement, • Teaching About the Danger Signs of Pregnancy Assessment of Fetal Well-Being Ultrasonography, • Doppler Flow Studies, • Alpha-Fetoprotein Analysis, • Marker Screening Tests, • Nuchal Translucency Screening, • Amniocentesis, • Chorionic Villus Sampling, • Nonstress Test, • Biophysical Profile Nursing Management for the Common Discomforts of Pregnancy First-Trimester Discomforts, • Second-Trimester Discomforts, • ThirdTrimester Discomforts Nursing Management to Promote Self-Care Personal Hygiene, • Clothing, • Exercise, • Sleep and Rest, • Sexual Activity and Sexuality, • Employment, • Travel, • Immunizations and Medications Nursing Management to Prepare the Woman and Her Partner for Labor, Birth, and Parenthood Childbirth Education Classes, • Nursing Management and Childbirth Education, • Options for Birth Settings and Care Providers, • Preparation for Breast-Feeding or Bottle-Feeding, • Final Preparation for Labor and Birth

UNIT FOUR

LABOR AND BIRTH CHAPTER 13 Labor and Birth Process Introduction Initiation of Labor Premonitory Signs of Labor Cervical Changes, • Lightening, • Increased Energy Level, • Bloody Show, • Braxton Hicks Contractions, • Spontaneous Rupture of Membranes True Versus False Labor Factors Affecting the Labor Process Passageway, • Passenger, • Powers, • Position (Maternal), • Psychological Response, • Philosophy, • Partners, • Patience, • Patient (Client) Preparation: Prenatal Education, • Pain Management Physiologic Responses to Labor Maternal Responses, • Fetal Responses Stages of Labor First Stage, • Second Stage, • Third Stage, • Fourth Stage

CHAPTER 14 Nursing Management During Labor and Birth Introduction Maternal Assessment During Labor and Birth Vaginal Examination, • Assessing Uterine Contractions, • Performing Leopold’s Maneuvers Fetal Assessment During Labor and Birth Analysis of Amniotic Fluid, • Analysis of the FHR, • Other Fetal Assessment Methods Promoting Comfort and Providing Pain Management During Labor Nonpharmacologic Measures, • Pharmacologic Measures Nursing Care During Labor and Birth Nursing Management During the First Stage of Labor, • Nursing Management During the Second Stage of Labor, • Nursing Management During the Third Stage of Labor, • Nursing Management During the Fourth Stage of Labor

UNIT FIVE

POSTPARTUM PERIOD CHAPTER 15 Postpartum Adaptations Introduction Maternal Physiologic Adaptations Reproductive System Adaptations, • Cardiovascular System Adaptations, • Urinary System Adaptations, • Gastrointestinal System Adaptations, • Musculoskeletal System Adaptations, • Integumentary System Adaptations, • Respiratory System Adaptations, • Endocrine System Adaptations, • Weight Loss After Childbirth Cultural Considerations for the Postpartum Period Balance of Hot and Cold, • Postpartum Cultural Beliefs Psychological Adaptations Parental Attachment Behaviors, • Maternal Psychological Adaptations, • Partner Psychological Adaptations

CHAPTER 16 Nursing Management During the Postpartum Period Introduction Social Support and Cultural Considerations Nursing Assessment in the Postpartum Period Vital Signs Assessment, • Physical Examination, • Psychosocial Assessment Nursing Interventions Providing Optimal Cultural Care, • Promoting Comfort, • Assisting With Elimination, • Promoting Activity, Rest, and Exercise, • Preventing Stress Incontinence, • Assisting With Self-Care Measures, • Ensuring Safety, • Counseling About Sexuality and Contraception, • Promoting Maternal Nutrition, • Supporting the Woman’s Choice of Infant Feeding Method, • Teaching About Breast Care, • Promoting Family Adjustment and Well-Being, • Preparing for Discharge

UNIT SIX

THE NEWBORN

CHAPTER 17 Newborn Transitioning Introduction Physiologic Transitioning Cardiovascular System Adaptations, • Respiratory System Adaptations, • Body Temperature Regulation, • Hepatic System Function, • Gastrointestinal System Adaptations, • Renal System Changes, • Immune System Adaptations, • Integumentary System Adaptations, • Neurologic System Adaptations Behavioral Adaptations Behavioral Patterns, • Behavioral Responses

CHAPTER 18 Nursing Management of the Newborn Introduction Nursing Management During the Immediate Newborn Period Assessment, • Nursing Interventions Nursing Management During the Early Newborn Period Assessment, • Nursing Interventions

UNIT SEVEN

CHILDBEARING AT RISK CHAPTER 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications Introduction Bleeding During Pregnancy Spontaneous Abortion, • Ectopic Pregnancy, • Gestational Trophoblastic Disease, • Cervical Insufficiency, • Placenta Previa, • Abruptio Placentae, • Placenta Accreta Hyperemesis Gravidarum Pathophysiology, • Therapeutic Management, • Nursing Assessment, • Nursing Management Hypertensive Disorders of Pregnancy Chronic Hypertension, • Gestational Hypertension, • Preeclampsia and Eclampsia

Hellp Syndrome Pathophysiology, • Therapeutic Management, • Nursing Assessment, • Nursing Management Gestational Diabetes Blood Incompatibility Pathophysiology, • Nursing Assessment, • Nursing Management Amniotic Fluid Imbalances Polyhydramnios, • Oligohydramnios Multiple Gestation Therapeutic Management, • Nursing Assessment, • Nursing Management Premature Rupture of Membranes Therapeutic Management, • Nursing Assessment, • Nursing Management

CHAPTER 20 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations Introduction Diabetes Mellitus Pathophysiology, • Screening, • Therapeutic Management, • Nursing Assessment, • Nursing Management Cardiovascular Disorders Congenital and Acquired Heart Disease, • Hypertension in Pregnancy, • Chronic Hypertension Respiratory Conditions Asthma, • Tuberculosis Hematologic Conditions Iron-Deficiency Anemia, • Thalassemia, • Sickle Cell Anemia Autoimmune Disorders Systemic Lupus Erythematosus, • Multiple Sclerosis, • Rheumatoid Arthritis Infections Cytomegalovirus, • Rubella, • Herpes Simplex Virus, • Hepatitis B Virus, • Varicella Zoster Virus, • Parvovirus B19, • Group B Streptococcus, • Toxoplasmosis, • Women Who Are HIV Positive Vulnerable Populations Pregnant Adolescent, • The Advanced Maternal Age Woman, • The Obese Pregnant Woman, • The Pregnant Woman and Substance Abuse

CHAPTER 21 Nursing Management of Labor and Birth at Risk Introduction Dystocia Problems with the Powers, • Problems with the Passenger, • Problems with the Passageway, • Problems with the Psyche, • Nursing Assessment Alternative/Nontraditional Families Preterm Labor Therapeutic Management, • Nursing Assessment, • Nursing Management Post-Term Pregnancy Nursing Assessment, • Nursing Management Women Requiring Labor Induction and Augmentation Therapeutic Management, • Nursing Assessment, • Nursing Management Vaginal Birth After Cesarean Intrauterine Fetal Demise Nursing Assessment, • Nursing Management Women Experiencing an Obstetric Emergency Umbilical Cord Prolapse, • Placenta Previa, • Placental Abruption, • Uterine Rupture, • Amniotic Fluid Embolism Women Requiring Birth-Related Procedures Amnioinfusion, • Forceps- or Vacuum-Assisted Birth, • Cesarean Birth

CHAPTER 22 Nursing Management of the Postpartum Woman at Risk Introduction Postpartum Hemorrhage Pathophysiology, • Therapeutic Management, • Nursing Assessment, • Nursing Management Venous Thromboembolic Conditions Pathophysiology, • Nursing Assessment, • Nursing Management Postpartum Infection Metritis, • Surgical Site Infections, • Urinary Tract Infections, • Mastitis Postpartum Affective Disorders Postpartum Blues, • Postpartum Depression, • Postpartum Psychosis

UNIT EIGHT

THE NEWBORN AT RISK CHAPTER 23 Nursing Care of the Newborn with Special Needs Birth-Weight Variations Small-for-Gestational-Age Newborns, • Large-for-Gestational-Age Newborns Gestational Age Variations Preterm Newborn, • Late Preterm (“Near Term”) Newborn, • Post-Term Newborn, • Dealing With Perinatal Loss

CHAPTER 24 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions Introduction Acquired Disorders Perinatal Asphyxia, • Transient Tachypnea of the Newborn, • Respiratory Distress Syndrome, • Meconium Aspiration Syndrome, • Persistent Pulmonary Hypertension of the Newborn, • Bronchopulmonary Dysplasia/Chronic Lung Disease, • Retinopathy of Prematurity, • Periventricular–Intraventricular Hemorrhage, • Necrotizing Enterocolitis, • Infant of a Diabetic Mother, • Birth Trauma, • Newborns of Substance-Abusing Mothers, • Hyperbilirubinemia, • Neonatal Sepsis Congenital Conditions Congenital Heart Disease, • Neural Tube Defects, • Microcephaly, • Hydrocephalus, • Choanal Atresia, • Congenital Diaphragmatic Hernia, • Cleft Lip and Palate, • Esophageal Atresia and Tracheoesophageal Fistula, • Omphalocele and Gastroschisis, • Imperforate Anus, • Hypospadias, • Epispadias, • Bladder Exstrophy, • Congenital Clubfoot, • Developmental Dysplasia of the Hip, • Inborn Errors of Metabolism APPENDIX A Standard Laboratory Values APPENDIX B Clinical Paths APPENDIX C Cervical Dilation Chart APPENDIX D Weight Conversion Charts APPENDIX E Breast-Feeding and Medication Use

Index

Contents in Brief UNIT ONE INTRODUCTION TO MATERNITY, NEWBORN, AND WOMEN’S NURSING CHAPTER 1 Perspectives on Maternal, Newborn, and Women’s Health Care CHAPTER 2 Family-Centered Community-Based Care

UNIT TWO WOMEN’S HEALTH THROUGHOUT THE LIFESPAN CHAPTER 3 Anatomy and Physiology of the Reproductive Systems CHAPTER 4 Common Reproductive Issues CHAPTER 5 Sexually Transmitted Infections CHAPTER 6 Disorders of the Breasts CHAPTER 7 Benign Disorders of the Female Reproductive Tract CHAPTER 8 Cancers of the Female Reproductive Tract CHAPTER 9 Violence and Abuse

UNIT THREE PREGNANCY CHAPTER 10 Fetal Development and Genetics CHAPTER 11 Maternal Adaptation During Pregnancy CHAPTER 12 Nursing Management During Pregnancy

UNIT FOUR LABOR AND BIRTH CHAPTER 13 Labor and Birth Process CHAPTER 14 Nursing Management During Labor and Birth

UNIT FIVE POSTPARTUM PERIOD

CHAPTER 15 Postpartum Adaptations CHAPTER 16 Nursing Management During the Postpartum Period

UNIT SIX THE NEWBORN CHAPTER 17 Newborn Transitioning CHAPTER 18 Nursing Management of the Newborn

UNIT SEVEN CHILDBEARING AT RISK CHAPTER 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications CHAPTER 20 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations CHAPTER 21 Nursing Management of Labor and Birth at Risk CHAPTER 22 Nursing Management of the Postpartum Woman at Risk

UNIT EIGHT THE NEWBORN AT RISK CHAPTER 23 Nursing Care of the Newborn with Special Needs CHAPTER 24 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions APPENDIX A Standard Laboratory Values APPENDIX B Clinical Paths APPENDIX C Cervical Dilation Chart APPENDIX D Weight Conversion Charts APPENDIX E Breast-Feeding and Medication Use Index

unit one Introduction to Maternity, Newborn, and Women’s Nursing

1 Perspectives on Maternal, Newborn, and Women’s Health Care

KEY TERMS Affordable Care Act (ACA) case management certified nurse midwife (CNM) cultural competence culture doula evidence-based nursing practice family family-centered care

fetal mortality rate infant mortality rate informed consent maternal mortality ratio mortality neonatal mortality rate

Learning Objectives Upon completion of the chapter, you will be able to: 1. Characterize the key milestones in the evolution of childbirth in America. 2. Outline the major components, concepts, and influences associated with the nursing management of women and their families. 3. Compare the past definitions of health and illness with the current definitions. 4. Examine the factors that affect maternal, newborn, and women’s health. 5. Evaluate how society and culture can influence the health of women and their families. 6. Distinguish the health care barriers affecting women and their families. 7. Review the ethical and legal issues that may arise when caring for women and their families. Sophia Nappo, a 38-year-old woman pregnant with her third child, comes to the prenatal clinic for a routine follow-up visit. Her mother, Betty, accompanies her because Sophia’s husband is out of town. Sophia lives with her husband and two children, ages 4 and 9. She works part-time as a lunch aide in the local elementary school. What factors may play a role in influencing the health of Sophia and her family?

Words of Wisdom Being pregnant and giving birth is like crossing a narrow bridge: people can accompany you to the bridge, and they can greet you on the other side, but you walk that bridge alone.

INTRODUCTION A person’s ability to lead a fulfilling life and to participate fully in society depends largely on his or her health status. This is especially true for women, who commonly are responsible for not only their own health but that of others: their children and families. Thus, it is important to focus on the health of women and families. Habits and practices established during pregnancy and in early childhood can have profound effects on a person’s health and illness throughout life. As a society, creating a population that cares about women and their families and promotes solid health care and lifestyle choices is crucial. Maternal and newborn nursing encompasses a wide scope of practice typically associated with childbearing. It includes care of the woman before pregnancy, care of the woman and her fetus during pregnancy, care of the woman after pregnancy, promotion of a safe motherhood, and care of the newborn, usually during the first 6 weeks after birth. The overall goal of maternal and newborn nursing is to promote and maintain optimal health for the woman and her family. Nurses today have an unprecedented opportunity to improve the health and well-being of women and families. Events from birth to death, and every health care emergency in between, will likely involve the presence of a nurse. Involvement of a knowledgeable, supportive, comforting nurse often leads to a positive health care experience. Skilled nursing practice depends on a solid base of knowledge and clinical expertise delivered in a caring, holistic manner. Nurses, using their knowledge and passion, help meet the health care needs of their clients throughout the life span, whether the client is a pregnant woman, a fetus, a partner, or a woman with health-related problems. Nurses fill a variety of roles in helping clients to live healthier lives by providing direct care, emotional support, comfort, information, advice, advocacy, support, and counseling. Nurses are often “in the trenches” advocating for issues, drawing attention to the importance of health care for the client, and dealing with the lack of resources, the lack of access to health care, and the focus on acute care rather than education and prevention. This chapter presents a general overview of the health care of women and their families and describes the major factors affecting maternal, newborn, and women’s health. It also addresses health care information available to women and their families and improvements in diagnosis and treatments. Nurses need to

be knowledgeable about these concepts and factors to ensure that they provide up-to-date professional care.

EVOLUTION OF MATERNAL AND NEWBORN NURSING The health care of women has changed over the years due in part to changes in childbirth methods, social trends, changes in the health care system, and federal and state regulations. By reviewing historical events, nurses can gain a better understanding of the current and future status of maternal, newborn, and women’s health nursing (Box 1.1).

Historical Perspective Childbirth in colonial America was a difficult and dangerous experience. During the 17th and 18th centuries, women giving birth often died as a result of exhaustion, dehydration, infection, hemorrhage, or seizures (Mintz, 2013). Since most women gave birth to between five and eight children, their lifetime chances of dying in childbirth ran as high as one in eight. Death in childbirth was sufficiently common that many colonial women regarded pregnancy with dread. In addition to her anxieties about pregnancy, an expectant mother was filled with apprehension about the possible death of her newborn child. Approximately 50% of all children died before age 5 (King et al., 2015), compared with an infant mortality rate today of 6.17 infant deaths/1,000 live births (World Factbook, 2015). Centuries ago, “granny midwives” handled the normal birthing process for most women. Midwifery skills have traditionally been passed from one woman to another within families, grandmothers to mothers to daughters, and also through apprenticeship with a more experienced midwife. Physicians usually were called only in extremely difficult cases, and all births took place at home (Simmons, Rothman, & Norman, 2013). During the early 1900s, physicians attended about half the births in the United States. Midwives often cared for women who could not afford a doctor. Many women were attracted to hospitals because this showed affluence and hospitals provided pain management, which was not available in home births. In the 1950s, natural childbirth practices advocating birth without medication and focusing on relaxation techniques were introduced (Rabor, Taghipour, & Najmabadi, 2015). These techniques opened the door to childbirth education classes and helped bring the father back into the picture. Both partners could participate by taking an active role in pregnancy, childbirth, and parenting (Fig. 1.1).

Current Trends In many ways, childbirth practices in the United States have come full circle, as we see the return of the nurse midwife and the doula. The concept of women helping other women during childbirth is not new; women who labored and gave birth at home were traditionally attended by relatives and midwives (EvidenceBased Practice 1.1). A certified nurse midwife (CNM) has postgraduate training in the care of normal pregnancy and childbirth and is certified by the American College of Nurse Midwives. A doula is a birth assistant who provides emotional, physical, and educational support to the woman and family during childbirth and the postpartum period. Many nurses working in labor and birth areas today are credentialed in their specialty so that they can provide optimal care to the woman and her newborn. Childbirth choices are often based on what works best for the mother, child, and family.

BOX 1.1 CHILDBIRTH IN AMERICA: A TIME LINE

FIGURE 1.1 Today fathers and partners are welcome to take an active role in the pregnancy and childbirth experience. A. A couple can participate together in childbirth education classes. (Photo by Gus Freedman.) B. Fathers and partners can assist the woman throughout her labor and childbirth experience. (Photo by Joe Mitchell.)

EVIDENCE-BASED PRACTICE 1.1 WOMEN’S RESPONSE TO CONTINUOUS LABOR SUPPORT Throughout history, women have been helping other women in labor by providing emotional support, comfort measures, information, and advocacy. However, in recent years, this practice has waned, and facilities frequently adhere to strict specific routines that may leave women feeling “dehumanized.”

STUDY A study was done to assess the effects on mothers and their newborns of continuous, one-to-one intrapartum care compared to usual care. The study also evaluated routine practices and policies in the birth environment that might affect a woman’s autonomy, freedom of movement, and ability to cope with labor; who the caregiver was (a staff member of the facility or not); and when the support began (early or late in labor). All published and unpublished randomized clinical trials comparing continuous support during labor with usual care were examined. One author and one research assistant used standard methods for data collection and analysis and extracted the data independently. Clinical trial authors provided additional information. The researchers used relative risk for categorical data and weighted mean difference for continuous data. Twenty one studies from 15 countries involving 15,061 women were examined.

Findings Women receiving continuous intrapartum support had a greater chance of a spontaneous vaginal birth, reduced intrapartum analgesia, caused no harm; labors were shorter, and women were less likely to have a cesarean section or instrumental birth, regional analgesia, or a newborn with a low 5-minute Apgar score. These women also reported increased satisfaction with their labor and childbirth experience. Overall, the support, when provided by someone other than a facility staff member and initiated early in labor, proved to be more effective.

Nursing Implications Based on this research, it is clear that women in labor benefit from one-to-one support during labor. Nurses can use the information gained from this study to educate women about the importance of having a support person during labor and birth. Nurses can also act as client advocates in facilities where they work to foster an environment that encourages the use of support persons during the intrapartum period. The focus of nursing needs to be individualized, supportive, and collaborative with the family during their childbearing experience. In short, nurses should place the needs of the mother and her family first in providing a continuum of care. Although the study found that support is more effective when provided by someone other than a staff member, support from an individual is the key. Assigning the same nurse to provide care to the couple throughout the birthing experience also fosters a one-to-one relationship that helps meet the couple’s needs and promotes feelings of security. By meeting the couple’s needs, the nurse is enhancing their birthing experience. Hodnett, E. D., Gates, S., Hofmeyr, G. J., Sakala, C., & Weston, J. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7(2), CD003766.

CORE CONCEPTS OF MATERNAL, NEWBORN, AND WOMEN’S HEALTH NURSING Maternal, newborn, and women’s health nursing provides evidence-based care to the client within the context of the family unit. This care involves the implementation of an interdisciplinary plan in a collaborative manner to ensure continuity of care that is cost effective, quality oriented, and outcome focused. It involves family-centered, evidence-based, case-managed care.

Family-Centered Care Family-centered care is the delivery of safe, satisfying, high-quality health care that focuses on and adapts to the physical and psychosocial needs of the family. It is based on mutual trust and collaboration between the woman, her family, and the health care provider. It is a partnership approach of families and their caregivers that recognizes the strength and integrity of the family. These are the basic principles of family-centered care: • Childbirth is considered a normal, healthy event in the life of a family. • Childbirth affects the entire family, and relationships will change. • Families are capable of making decisions about their own care if given adequate information and professional support (Young, 2014). The philosophy of family-centered care recognizes the family as the constant. The health and functioning of the family affect the health of the client and other members of the family. Family members support one another well beyond the health care provider’s brief time with them, such as during the childbearing process or during a child’s illness. Birth is viewed as a normal life event rather than a medical procedure. Family-centered care requires the nurse to apply sensitivity to the client’s and family’s beliefs and those supporting their culture. This involves listening to the family’s needs and shifting the nurse’s authoritarian role to the family to empower them to make their own decisions within the context of a supportive environment. A true family perspective should be applied in maternity care and the new parents viewed as a family unit, not as a medical case. Nurses providing family-centered care means that they identify, respect, and care about client’s differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate clients; share decision making and management; and continuously advocate for them (Denham et al., 2016). With family-centered care, support and respect for the uniqueness and diversity of families are essential, along with encouragement and enhancement of the family’s strengths and competencies. It is important to create opportunities for families to demonstrate their abilities and skills. Families can also acquire new abilities and skills to maintain a sense of control. Family-centered care

promotes greater family self-determination, decision-making abilities, control, and self-efficacy, thereby enhancing the client’s and family’s sense of empowerment. When implementing family-centered care, nurses seek caregiver input; these suggestions and advice are incorporated into the client’s plan of care as the nurse counsels and teaches the family appropriate health care interventions. Today, as nurses partner with various experts to provide highquality and cost-effective care, one expert partnership that nurses can make is with the client’s family. Nurses empower mothers with freedom of choice based on knowledge of alternatives. This means the mother’s birth plan would be honored in an environment where the mother’s choices are respected. Nurses must partner with women and their families for optimal care and quality outcomes (Beal, Dalton, & Maloney, 2015). The impact of family-centered care can be seen in the models of care delivery for women. Families are kept together after childbirth, not separated as in past years. From the 1980s to the present, increased access to care for all women (regardless of their ability to pay) and hospital redesigns have focused on keeping families together during their childbirth experience (Clark, Beatty, & Reibel, 2015). Hospital redesigns include labor, delivery, and recovery rooms that incorporate all three activities in one room, and labor, delivery, recovery, and postpartum (LDRP) spaces that incorporate all four activities in one room, so that families don’t have to move from place to place during the birth experience (Fig. 1.2).

FIGURE 1.2 Providing an opportunity for the “big brother” to interact with his new siblings is an important component of family-centered nursing care.

Evidence-Based Care Evidence-based practice (EBP) is a problem-solving approach to making nursing clinical decisions (Hanrahan et al., 2015). It involves the collection, interpretation, and integration of validated research-derived evidence from a variety of resources such as research findings, internal evidence from outcome management or process improvement processes, and patient preferences. Nurses need to find a way to integrate the best available evidence to translate into practice to achieve the best outcomes consistent with the aim of health care—to improve the experience of care, to improve the health of mothers and infants, and to reduce the costs of health care (Hain & Kear, 2015). Evidence-based nursing practice involves the use of research to establish a plan of care and to implement that care. This model of nursing practice includes the use of the best current evidence in making decisions about care. Widespread use of EBP may lead to a decrease in variation of care while at the same time increase in quality. Scientific research findings help nurses not only stay current in their clinical specialties, but also in their choice of the most effective interventions. Many of the professional organizations—for example, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), the American Nurses Association (ANA), and the National League for Nursing (NLN)—have developed evidence-based clinical practice guidelines for the safest and most effective delivery of family-centered nursing care. Nurses should be diligent in seeking out these evidence-based guidelines to ensure excellence in their daily practice. When EBP is delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best client outcomes can be achieved. The landmark report by the Health and Medicine Division (HMD) (2011), The Future of Nursing: Leading Change, Advancing Health, listed EBP as a competency required to enhance patient care quality and safety. Thus, it is no longer an option to incorporate EBP into our practice, but a necessity!

Case-Managed Care Modern health care focuses on an interdisciplinary plan of care designed to meet a client’s physical, developmental, educational, spiritual, and psychosocial needs. This interdisciplinary collaborative type of care is termed case management, a process of assessment, planning, application, coordination, follow-up, and evaluation of the options and services required to meet an individual’s health needs through communication and available resources to promote quality cost-effective results. Operational excellence, quality of care, and sound financial performance are increasingly linked as key drivers of health care performance. Quality case management for all families contributes toward fewer complications, reductions in length of stay, and lowered costs. Case management is a continuous process that requires critical thinking about how care is delivered and its effect on the entire care progression of a client. It has, at its core, the values of care coordination, utilization management, and client advocacy across the continuum of care (Summers, 2016) and involves the following components: • Advocacy, communication, and resource management • Client-focused comprehensive care across a continuum • Coordinated care with an interdisciplinary approach (Treadwell et al., 2015) When the nurse effectively functions in the role of case manager, client and family satisfaction is increased, fragmentation of care is decreased, and outcome measurement for a homogenous group of clients is possible. Think back to Sophia and her mother, Betty, who were described at the beginning of the chapter. Sophia and her husband are planning to use natural childbirth and to have their children present for the birth. While Sophia is waiting to be called for her appointment, Betty says, “Things have changed so much since I was pregnant. It’s amazing what happens nowadays.” Explain how things have changed in maternal and newborn health care, focusing on the concept of family-centered care.

HEALTH STATUS GOALS At one time, health was defined simply as the absence of disease; health was measured by monitoring the mortality and morbidity of a group. During the past century, however, the focus on health has shifted to disease prevention, health promotion, and wellness. The World Health Organization (WHO, 2015a) defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” The definition of health is complex; it is not merely the absence of disease or an analysis of mortality and morbidity statistics.

Healthy People 2020 In 1979, a surgeon general’s report titled Healthy People presented a prevention agenda for the nation that identified the most significant preventable threats to the health of the United States. Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States. The current initiative is Healthy People 2020, which is the country’s comprehensive, nationwide health promotion and disease prevention agenda that promotes the goal of improving the health and well-being of women, infants, children, and families (U.S. Department of Health & Human Services [USDHHS], 2015a). Ten specific health indicators serve as a way to evaluate progress made in the public health arena and to coordinate the national health improvement efforts. Healthy People 2020 highlights the major health indicators of the 21st century that need to be addressed. This also outlines major goals intended to increase the quality and years of healthy life and to eliminate health disparities among ethnic groups by targeting the lifestyle choices and environmental conditions that contribute to over half of all premature deaths in the United States. Healthy People 2020 identifies specific national health goals related to maternal, infant, and child health. Improving the well-being of mothers, infants, and children is an important public health goal for the United States. Their well-being determines the health of the next generation and can help predict future public health challenges for families, communities, and the health care system. The objectives of the maternal, infant, and child health topic area address a wide range of conditions, health behaviors, and health system indicators that affect the health, wellness, and quality of life of women, children, and families (USDHHS, 2015a). Measuring health status is not a simple or convenient process. For example, some individuals with chronic illnesses do not see themselves as ill if they can control their condition through self-management. A traditional method used in this country to measure health is to examine mortality and morbidity data. Information is collected and analyzed to provide an objective description of the nation’s health.

HEALTHY PEOPLE 2020 • 1.1 Major Health Concerns of the 21st Century • Physical activity • Overweight and obesity • Tobacco use • Substance abuse • Responsible sexual behavior • Mental health • Injury and violence • Environmental quality • Immunizations • Access to health care Healthy People objectives based on data from http://www.healthypeople.gov.

HEALTHY PEOPLE 2020 • 1.2 National Health Goals—Maternal, Infant, and Child Health • Reduce the rate of fetal and infant deaths. • Reduce the rate of maternal mortality. • Reduce the 1-year mortality rate for infants with Down syndrome. • Reduce maternal illness and complications due to pregnancy. • Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women. • Reduce low-birth-weight (LBW) and very-low-birth-weight (VLBW) births. • Reduce preterm births. • Increase the proportion of pregnant women who receive early and adequate prenatal care. • Increase abstinence from alcohol, cigarettes, and illicit drugs among

pregnant women. • Increase the proportion of pregnant women who attend a series of prepared childbirth classes. • Increase the proportion of mothers who achieve a recommended weight gain during their pregnancies. • Increase the proportion of women of childbearing potential with an intake of at least 400 μg of folic acid from fortified foods or dietary supplements. • Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations. • Increase the proportion of women delivering a live birth who received preconception care services and practiced key recommended preconception health behaviors. • Reduce the proportion of persons aged 18–44 years who have impaired fecundity (i.e., a physical barrier preventing pregnancy or carrying a pregnancy to term). • Reduce postpartum relapse of smoking among women who quit smoking during pregnancy. • Increase the proportion of women giving birth who attend a postpartum care visit with a health worker. • Increase the proportion of infants who are put to sleep on their backs. • Increase the proportion of infants who are breast-fed. • Increase the proportion of employers that have worksite lactation support programs. • Reduce the proportion of breast-fed newborns who receive formula supplementation within the first 2 days of life. • Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies. • Reduce the occurrence of fetal alcohol syndrome. • Reduce the proportion of children diagnosed with a disorder through newborn blood spot screening who experience developmental delay requiring special education services. • Reduce the proportion of children with cerebral palsy born as LBW infants (less than 2,500 g). • Reduce occurrence of neural tube defects. • Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems.

• Increase appropriate newborn blood-spot screening and follow-up testing. • Increase the proportion of VLBW infants born at level III hospitals or subspecialty perinatal centers. Healthy People 2020 objectives based on data from http://www.healthypeople.gov.

Mortality Mortality is the incidence or number of individuals who have died over a specific period. This statistic is presented as rates per 100,000 and is calculated from a sample of death certificates. The National Center for Health Statistics, under the USDHHS, collects, analyzes, and disseminates the data on mortality rates in the United States.

Maternal Mortality The maternal mortality ratio is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy. It is reported as a ratio of deaths per 100,000 live births, for a specified year. In the United States, the maternal mortality ratio is mixed depending on ethnic background. African American women suffer maternal mortality ratios three-tofourfold increase when compared to those of any other ethnic group: about 35.6 of 100,000 African American mothers die due to childbirth, as compared with much lower rates in Whites (11.7), and women of other races (17.6) (Centers for Disease Control and Prevention [CDC], 2015a). The federal government has pledged to improve maternal–child care outcomes and thus reduce mortality ratios for women and children by endorsing the Healthy People 2020 agenda, but the WHO (2015d) data show that the United States ranks 50th out of approximately 240 nations in the world for maternal mortality—with maternal mortality ratios higher than almost all European countries, as well as several countries in Asia and the Middle East. This statistic places the United States near the bottom of the top quartile of developed countries. For a country that spends more than any other country on health care and more on childbirth-related care than any other area of hospitalization—US $86 billion a year—this is a shockingly poor return on investment (International Center for Research on Women, 2015). During the past several decades, mortality and morbidity have dramatically decreased as a result of an increased emphasis on hygiene, good nutrition, exercise, and prenatal care for all women. However, women are still

experiencing complications at significant rates. The United States is one of the most medically and technologically advanced nations and has the highest per capita spending on health care in the world, but the maternal mortality rate has steadily increased over the years. The United States is one of only eight countries where maternal mortality is on the rise. The other countries include Afghanistan, Greece, Africa, and Central America (Kassebaum et al., 2014). Our current mortality rates indicate the need for improvement. For example: • Two or three women die in the United States every day from pregnancy complications, and more than 30% of pregnant women (1.8 million women annually) experience some type of illness or injury during childbirth (Abel, 2015). • The United States ranks 50th (in other words, below 49 other countries) in rates of maternal deaths (deaths per 100,000 live births) (WHO, 2015d). • Most pregnancy-related complications are preventable. The top five leading causes of pregnancy-related mortality are embolism (20%), hemorrhage (17%), preeclampsia and eclampsia (16%), infection (13%), and cardiomyopathy (8%) (Chescheir, 2015). The maternal mortality and morbidity rates for African American women have been three to four times higher than those for Whites (Creanga et al., 2015). This major racial disparity has persisted for more than 60 years, with African American women having at least a doubled risk of pregnancy-related death when compared with White women. This striking difference in the pregnancy-related mortality ratio is the largest disparity in the area of maternal and child health. Researchers do not entirely understand what accounts for this disparity, but some suspected causes of the higher maternal mortality rates for minority women include low socioeconomic status, limited or no insurance coverage, bias among health care providers (which may foster distrust), and quality of care available in the community. Language and legal barriers may also explain why some immigrant women do not receive good prenatal care. Lack of care during pregnancy is a major factor contributing to a poor outcome. Prenatal care is well known to prevent complications of pregnancy and to support the birth of healthy infants, but not all women receive the same quality and quantity of health care during their pregnancy. Pregnancy-related mortality is on the rise in the United States. The Healthy People 2020 goal for maternal deaths is 11.4 per 100,000 live births (USDHHS, 2015a). African American pregnant women had higher

degrees of hypertension and lower hemoglobin levels on admission and had presented for prenatal care much later, on average, than White women or not at all (Creanga et al., 2015). The Centers for Disease Control and Prevention (CDC) has noted that the disparity in maternal mortality rates between women of color and White women represents one of the largest racial disparities among public health indicators. Eliminating racial and ethnic disparities in maternal–child health care requires enhanced efforts at preventing disease, promoting health, and delivering appropriate and timely care (CDC, 2015a). The CDC has called for more research and monitoring to understand and address racial disparities, along with increased funding for prenatal and postpartum care. Research is needed to identify causes and to design initiatives to reduce these disparities, and the CDC is calling on Congress to expand programs to provide preconception and prenatal care to underserved women.

Fetal Mortality The fetal mortality rate or fetal death rate refers to the spontaneous intrauterine death of a fetus at any time during pregnancy per 1,000 live births. Fetal deaths later in pregnancy >20 weeks of gestation are also referred to as stillbirths. Fetal mortality may be attributable to maternal factors (e.g., malnutrition, disease, or preterm cervical dilation) or fetal factors (e.g., chromosomal abnormalities or poor placental attachment). Fetal mortality is a major, but often overlooked, public health problem. This refers to spontaneous intrauterine death at any time during pregnancy. The fetal mortality rate in the United States is 6.2 per 1,000 live births (CDC, 2015b). The goal of Healthy People 2020 is to reduce it to 5.6 fetal deaths (USDHHS, 2015a). Much of the public concern regarding reproductive loss has concentrated on infant mortality, because less is known about fetal mortality. However, the impact of fetal mortality on families in the United States is considerable, because it provides an overall picture of the quality of maternal health and prenatal care.

Neonatal and Infant Mortality The neonatal mortality rate is the number of infant deaths occurring in the first 28 days of life per 1,000 live births. The United States now ranks 41st in the world in terms of neonatal mortality, the death rate of infants less than 1 month old. The neonatal mortality rate is 4.5 per 1,000 live births (USDHHS, 2015b;

World Bank, 2015). The goal of Healthy People 2020 is to reduce it to 4.1 (USDHHS, 2015a). Each year the deaths of 2 million babies are linked to complications during birth or within the first month and the burden is inequitably carried by the poor. Evidence-based strategies are urgently needed to reduce the burden of intrapartum-related deaths (CDC, 2015c). The reliability of the neonatal mortality estimates depends on the accuracy and completeness of reporting and recording of births and deaths. Underreporting and misclassification are common, especially for deaths occurring early in life. The perinatal mortality rate encompasses late and early neonatal mortalities and is defined as the number of stillbirths and deaths in the first week of life per 1,000 live births; it is also a useful health status indicator. Work is ongoing to improve estimates of stillbirth rates, a major component of perinatal mortality (WHO, 2015b). Perinatal mortality rate is a sum total of the following: • Fetal mortality rate—the death of a fetus prior to expulsion or extraction from the mother. Fetal death is determined by no signs of life after birth. • Neonatal mortality rate—the number of neonates dying before reaching 28 days of life, per 1,000 live births in a given year. The infant mortality rate is the number of deaths occurring in the first 12 months of life. It is also documented as the number of deaths of infants younger than 1 year of age per 1,000 live births. Neonatal mortality and postneonatal mortality (covering the remaining 11 months of the first year of life) are reflected in the infant mortality rate. The infant mortality rate is used as an index of the general health of a country. Currently, about two thirds of infant deaths in the United States occur before 28 days, with the remaining third occurring in the postnatal period between 28 days and under 1 year (USDHHS, 2015a). Generally, this statistic is one of the most significant measures of maternal and child health. In the United States, the infant mortality rate is 6.17 (World Fact Book, 2015). Healthy People 2020’s goal is to reduce it to 6.0 (USDHHS, 2015a). Despite the rapid decline in infant mortality for industrialized countries during the 21st century, the infant mortality rate in the United States has declined only marginally. Racial and ethnic disparities in infant mortality have persisted and increased, as have the percentages of preterm and low-birth-weight births. Infant mortality is a complex and multifactorial problem that has proved resistant to intervention efforts (McGill, 2015). The infant mortality rate varies greatly from state to state as well as among

ethnic groups. The United States has one of the highest gross national products in the world and is known for its technological capabilities, the United States continues to lag behind in preserving infant’s lives when compared with other industrialized countries (CDC, 2015d). The main causes of early infant death in this country include problems occurring at birth or shortly thereafter. These include prematurity, low birth weight, congenital anomalies, sudden infant death syndrome (SIDS), and respiratory distress syndrome (Oza et al., 2015).

Take Note! African American and American Indian/Alaska Native infants have consistently had higher infant mortality rates than other ethnic groups (Kail & Cavanaugh, 2016). Congenital anomalies remain the leading cause of infant mortality in the United States. Low birth weight and prematurity are major indicators of infant health and significant predictors of infant mortality (Wang et al., 2015). The high incidence of low birth weight (2 years) of Depo-Provera and bone loss (Wolfe & Cansino, 2015). It is not entirely clear if this loss in bone mineral density (BMD) is reversible because there have not been any long-term prospective studies in current and past users. It is highly recommended that bone density scans be done while on Depo-Provera (Curtis, 2014). TRANSDERMAL PATCHES Transdermal delivery of contraceptive hormones avoids hepatic first-pass metabolism, allowing a lower total hormone dose when compared to that of oral products that are metabolized in the liver. A transdermal patch, Ortho Evra, is available in the United States. It is a matchbox-sized patch containing hormones that are absorbed through the skin when placed on the lower abdomen, upper outer arm, buttocks, or upper torso (avoiding the breasts). The patch is applied weekly for 3 weeks, followed by a patch-free week during which withdrawal bleeding occurs. The patch delivers continuous levels of progesterone and estrogen. Transdermal absorption allows the drug to enter the bloodstream directly, avoiding rapid inactivation in the liver known as first-pass metabolism. Because estrogen and progesterone are metabolized by liver enzymes, avoiding first-pass metabolism was thought to reduce adverse effects. However, recent evidence suggests that the risk of venous thrombosis and embolism is increased with the patch and the risk of skin burns occurring if undergoing an MRI, but still less than the risk of venous thromboembolism during pregnancy (Nelson,

2015). Additional studies are under way to understand the clinical significance of these latest findings, but in the interim nurses need to focus on ongoing risk assessment and should be prepared to discuss current research findings with clients. Adherence to the regimen of combination contraceptive patch use has been shown to be significantly greater than adherence with OCs. In addition, research suggests that overweight and obese women with weights exceeding 198 pounds should be advised of the potentially decreased effectiveness of the patch and increase incidence of venous thromboembolism and weight gain (Pocius & Dutton, 2015). The patch provides combination HT with a side-effect profile similar to that of OCs (Fig. 4.14). VAGINAL RINGS Approved in 2001 by the FDA, the vaginal ring contains both estrogen and progesterone hormones. The contraceptive vaginal ring, NuvaRing, is a flexible, soft, transparent ring that is inserted by the user for a 3-week period of continuous use followed by a ring-free week to allow withdrawal bleeding (Fig. 4.15). Ethinyl estradiol and etonogestrel are rapidly absorbed through the vaginal epithelium and result in a steady serum concentration. Because the hormones are released directly into the vagina, a lower daily dose of hormones is required in comparison with OC doses. Studies have demonstrated that the efficacy and safety of the ring are equivalent to those of OCs. Clients report being highly satisfied with the vaginal ring and report fewer systemic side effects than do OC users. The ring provides effective cycle control as well as symptom relief for women with menorrhagia, dysmenorrhea, and polycystic ovarian syndrome. Reported problems associated with the use of vaginal rings include erosion of vaginal wall, ring expulsion, interference with coitus, unpleasant ring odor, and premature discontinuation due to vaginal discomfort (Khan & Krupanidhi, 2015). The ring can be inserted by the woman and does not have to be fitted. The woman compresses the ring and inserts it into the vagina, behind the pubic bone, as far back as possible, but precise placement is not critical. The hormones are absorbed through the vaginal mucosa. It is left in place for 3 weeks and then removed and discarded. Effectiveness and adverse events are similar to those seen with combination OCs. Clients need to be counseled regarding timely insertion of the ring and what to do in case of accidental expulsion. Recent studies suggest that a vaginal ring containing etonogestrel and ethinyl estradiol used in an extended regimen is a safe contraceptive method that offers good

cycle control and can be an option for women who have gastric intolerance or other side effects when using oral hormonal contraceptives (King et al., 2015).

FIGURE 4.14 Transdermal patch.

FIGURE 4.15 Vaginal ring.

IMPLANTABLE CONTRACEPTIVES The implant is a subdermal time-release method that delivers synthetic progestin that inhibits ovulation. Once in place, it delivers 3 years of continuous, highly effective contraception. Like POPs, implants act by inhibiting ovulation and thickening cervical mucus, so sperm cannot penetrate. A single-rod progestin implant (Nexplanon) is currently available in the United States. Nexplanon is 4 cm long and 2 mm in diameter, and contains 68 mg of the hormone progestin. The implant is radio-opaque and is over 99% effective (King

et al., 2015). The side effects are also similar to those of POPs: irregular bleeding, headaches, weight gain, breast tenderness, and depression. Fertility is restored quickly after it is removed. Implants require a minor surgical procedure for both insertion and removal. The implants do not offer any protection against STIs. Hormonal side effects are not exclusive to implants but tend to be a problem with all hormonal contraceptives. Preinsertion counseling by the nurse is essential to prepare the woman for any such side effects. Expert counseling should cover the one side effect most likely to cause discontinuation: initial irregular bleeding and the possibility of amenorrhea with longer use (Craik & Rowlands, 2015). INTRAUTERINE CONTRACEPTIVES Intrauterine contraceptives are classified as either hormonal or nonhormonal. Both types prevent pregnancy via inhibition of sperm mobility and sperm viability and change the speed of transport of the ovum in the fallopian tube. An intrauterine contraceptive (IUC) is a small plastic T-shaped object that is placed inside the uterus to provide contraception (Fig. 4.16). It prevents pregnancy by making the endometrium of the uterus hostile to implantation of a fertilized ovum by causing a nonspecific inflammatory reaction and inhibiting sperm and ovum from meeting (Wildemeersch & Jandi, 2015). The hormonal IUC will make monthly periods lighter, shorter, and less painful, making this a useful method for women with heavy, painful periods. The implants contain either copper or progesterone to enhance their effectiveness. One or two attached strings protrude into the vagina so that the user can check for placement.

FIGURE 4.16 A. Intrauterine contraceptive. B. An IUC in place in the uterus.

Currently three IUCs are available in the United States: the copper ParaGardTCu-380A, the levonorgestrel-releasing intrauterine system (LNG-IUS) marketed as Mirena, and another LNG-IUD marketed as Skyla. The ParaGardTCu-380A is approved for 10 years of use and is nonhormonal. Its mechanism of action is based on the release of copper ions, which alone are spermicidal. Additionally, the device causes an inflammatory action leading to a hostile uterine environment. The TCu-380A is also approved for use as emergency contraception. Mirena provides intrauterine conception for 5 years, but has been shown to be effective for as long as 7 years. Skyla has been approved for 3 years of pregnancy prevention. Both devices release a low dose of progestin causing thinning of the endometrium and thickening of cervical mucus, which inhibits sperm entry into the upper genital tract. Their use results in a major reduction in menstrual flow and dysmenorrhea, suggesting that they are viable alternative to hysterectomy and endometrial ablation in women with menorrhagia (Atkin et al., 2015). An advantage of these hormonally impregnated intrauterine systems is that they are relatively maintenance-free: users must consciously discontinue using them to become pregnant rather than making a daily decision to avoid conception (Alan Guttmacher Institute, 2015a). The IUCs provide a safe, highly effective, long-lasting, yet reversible method of contraception. Expanding access to intrauterine contraception is an important measure to reduce the rate of unintended pregnancy in the United States. Nurses should consider including them in their discussion to appropriate candidates, including women who are nulliparous, adolescent, immediately postpartum, or postabortion, and those who desire emergency contraception, and as an alternative to permanent sterilization. Limitations barriers to obtaining intrauterine contraception such as requiring cervical cancer screening before insertion, routine testing for gonorrhea and chlamydial infection in low-risk women, or scheduling insertion only during menses are unnecessary. IUC insertion can take place on any day of the menstrual cycle, if absence of pregnancy is confirmed (Cheng & Van Leuven, 2015). Box 4.7 highlights the warning signs of the potential complications of IUCs. EMERGENCY CONTRACEPTION Unplanned pregnancy is a major health, economic, and social issue for women. Approximately one third of all unplanned pregnancies end in abortion (CDC, 2015b). Using an emergency contraceptive provides a woman a second chance to prevent an unintended pregnancy. Emergency contraception (EC) reduces

the risk of pregnancy after unprotected intercourse or contraceptive failure such as condom breakage (Raymond & Cleland, 2015). It is used within 72 hours of unprotected intercourse to prevent pregnancy. The sooner ECs are taken, the more effective they are. They reduce the risk of pregnancy for a single act of unprotected sex by almost 80% (Samra-Latif & Wood, 2015). The methods available in the United States are POPs, Plan B One-Step (Fig. 4.17), Next Choice, Next Choice One Dose; combined estrogen and progestin pills, or insertion of a copper-releasing intrauterine system up to 7 days after unprotected intercourse. Ulipristal acetate (marketed as Ella) is a selective progesterone receptor modulator that, when taken as a single 30-mg dose, is a new, safe, and effective emergency contraceptive that can be used from the first day and up to 5 days following unprotected intercourse. The older progesterone-only emergency contraceptive, levonorgestrel, is taken as two 0.75-mg pills 12 hours apart (Next Choice®; Watson Pharmaceuticals Inc., Morristown, NJ, USA) or as a single 1.5mg pill (Plan B One-Step™; Watson Pharmaceuticals Inc.), and is approved for only 72 hours after unprotected intercourse (Mulligan, 2015).

BOX 4.7 WARNINGS FOR INTRAUTERINE SYSTEM USERS OF POTENTIAL COMPLICATIONS • P = Period late, pregnancy, abnormal spotting or bleeding • A = Abdominal pain, pain with intercourse • I = Infection exposure, abnormal vaginal discharge • N = Not feeling well, fever, chills • S = String length shorter or longer or missing Adapted from King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery. Burlington, MA: Jones & Bartlett Learning.

FIGURE 4.17 Emergency contraceptive kit.

Access to emergency contraceptives has been controversial for minors. Prior to 2013, the pills were available by prescription only, and even when approved for nonprescription status, access was restricted based on age. In 2013, several judicial courts and the FDA ruled in favor of nonprescription access to EC by all women regardless of age. At this time, the federal government has not appealed these rulings, but many states have placed restrictions on access of EC (Casey & Isaacs, 2015). The only contraindication to the use of any of the four EC

methods is a known pregnancy as defined as implantation. Although access to EC has increased with nonprescription status and approval of Plan B One-Step without age restrictions, many barriers remain in public awareness and unintended pregnancies continue to rise. Because of the lack of awareness of EC and the politics surrounding it, EC is not used as widely as would be warranted by the incidence of unprotected coitus. Nurses need to educate their female clients to bring about increased awareness of this second chance method. Table 4.5 lists recommended oral medication and intrauterine regimens. Prime points to stress concerning ECs are the following: • ECs do not offer any protection against STIs or future pregnancies. • ECs should not be used in place of a regular birth control method, because they are less effective. • ECs may delay the next menses, so evaluation for pregnancy is needed if menses does not occur within three weeks after EC use • Report any severe abdominal pain to health care provider immediately. • ECs are regular birth control pills given at a higher dose. • ECs are contraindicated during pregnancy (Ilic, 2015).

Take Note! Contrary to popular belief, ECs do not induce abortion and are not related to mifepristone or RU-486, the so-called abortion pill approved by the FDA in 2000. Mifepristone chemically induces abortion by blocking the body’s progesterone receptors, which are necessary for pregnancy maintenance. ECs simply prevent embryo creation and uterine implantation from occurring in the first place. There is no evidence that ECs have any effect on an already implanted ovum. The side effects are nausea and vomiting. TABLE 4.5 EMERGENCY POSTCOITAL CONTRACEPTION OPTIONS

FIGURE 4.18 Laparoscopy for tubal sterilization.

Sterilization Sterilization is a permanent, safe, and highly effective method of contraception for those who are certain they do not want any or any more children. Vasectomy is the only highly reliable form of male contraception. Approximately 600,000 tubal occlusions and 200,000 vasectomies are performed in the United States annually and over 220 million worldwide (ACOG, 2013). It is the most widely used method of family planning in the world in both developed and developing countries. Sterilization refers to surgical procedures intended to render the person infertile. Laparoscopic, abdominal, and hysteroscopic methods of female sterilization are available in the United States, with most of these procedures performed outside the hospital. Sterilization is a safe and effective form of permanent birth control. In the United States, it is still the second most commonly used form of contraception overall and is the most frequently used method among married women and among women over 30 years of age (McKay

& Schunmann, 2015). More women than men undergo surgical sterilization. According to the CDC (2015b), approximately 18% of women undergo female sterilization in comparison with 7% of men in the United States. Sterilization should be considered a permanent end to fertility because reversal surgery is difficult, expensive, and not always successful. Because these methods are intended to be irreversible, all couples should be appropriately counseled about the permanency of sterilization and the availability of highly effective, longacting, reversible methods of contraception before their decision is made. TUBAL LIGATION Tubal ligation, the sterilization procedure for women, can be performed postpartum, after an abortion, or as an interval procedure unrelated to pregnancy. Mini-laparotomies and laparoscopies are the two most common techniques. In the laparoscopy procedure, the abdomen is filled with carbon dioxide gas so that the abdominal wall balloons away from the tubes to provide a view of the fallopian tubes. They are grasped and sealed with a cauterizing instrument or with rings, bands, or clips, or cut and tied (Fig. 4.18). ESSURE Essure is a nonsurgical, nonhormonal, permanent birth control method that is 99% effective. This method is for women who desire no more children as it is a permanent method of birth control. It offers several advantages over a conventional tubal ligation: general anesthesia and incisions are not needed, thereby increasing safety, lowering costs, and improving access to sterilization. A tiny coil (Essure) is introduced and released into the fallopian tubes through the cervix. The coil promotes tissue growth in the fallopian tubes, and over a period of 3 months, this growth blocks the tubes. The build-up of tissue creates a barrier that keeps sperm from the reaching the ovum, thus preventing conception (Thurkow, 2015). This less-invasive technique uses a hysteroscopy under local anesthesia in an office setting. Sterilization does not occur immediately after this procedure, so women must be educated to use additional contraception for 3 months until permanent tubal occlusion is verified. VASECTOMY Male sterilization is accomplished with a surgical procedure known as a vasectomy. More than 500,000 men have a vasectomy performed in the United

States each year (Mcfarlane, 2015). It is usually performed under local anesthesia in a urologist’s office, and most men can return to work and normal activities in a day or two. The procedure involves making a small incision into the scrotum and cutting the vas deferens, which carries sperm from the testes to the penis (Fig. 4.19). Complications from vasectomy are rare and minor in nature. Immediate risks include infection, hematoma, and pain. After vasectomy, semen no longer contains sperm. This is not immediate, though, and the man must submit semen specimens for analysis 8 to 16 weeks after a vasectomy until two specimens show that no sperm is present. When the specimen shows azoospermia, the man’s sterility is confirmed (Whitaker, 2015).

FIGURE 4.19 Vasectomy. A. Site of vasectomy incisions. B. The vas deferens is cut with surgical scissors. C. Cut ends of the vas deferens are cauterized to ensure blockage of the passage of sperm. D. Final skin suture.

Nursing Management of the Woman Choosing a Contraceptive Method The choice of a contraceptive method is a very personal one involving many factors. What makes a woman choose one contraceptive method over another? In making contraceptive choices, couples must balance their sexual lives, their reproductive goals, and each partner’s health and safety. The search for a choice that satisfies all three objectives is challenging. A method that works for a sexually active teenage girl may not meet her needs later in life. Several considerations influence a person’s choice of contraceptives: • Motivation • Cost • Cultural and religious beliefs (Box 4.8) • Convenience • Effectiveness • Side effects • Desire for children in the future • Safety of the method • Comfort level with sexuality • Protection from STIs • Interference with spontaneity If a contraceptive is to be effective, the woman must understand how it works, must be able to use it correctly and consistently, and must be comfortable and confident with it. If a client cannot adhere to taking a pill daily, consider a method used once a week (transdermal patches), once every 3 weeks (transvaginal ring), or once every 3 months (Depo-Provera injection). Another option may be a progesterone IUC that lasts 3 to 5 years and reduces menstrual flow significantly. Regardless of which method is chosen, the client’s needs should be paramount in the discussion. The nurse can educate clients about which methods are available and their advantages and disadvantages, efficacy, cost, and safety. Knowledge of contraceptive effectiveness is crucial to making an informed

choice. The couple has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness. Counseling can help the woman choose a contraceptive method that is efficacious and fits her preferences and lifestyle.

BOX 4.8 SELECTED RELIGIOUS CHOICES FOR FAMILY PLANNING AND ABORTION • Roman Catholic—Abstinence and natural family planning; no abortion • Judaism (Orthodox)—Family planning and abortion accepted in first trimester. Conservative and Reform Judaism accept both family planning and abortion. • Islam—Family planning accepted; abortion only for serious reasons • Protestant Christianity—Firmly in favor of family planning; mixed on abortion • Buddhism—Long experience with family planning and abortion • Hinduism—Accept both family planning and abortion • Native American religions—Accept both family planning and abortion • Chinese religions—Taoism and Confucianism accept both Adapted from McFarland, M. R., & Wehbe-Alamah, H. B. (2015). Leininger’s cultural care diversity and universality: A worldwide nursing theory (3rd ed.). Burlington, MA: Jones & Bartlett Learning; and McFarlane, D. R. (2015). Global population and reproductive health. Burlington, MA: Jones & Bartlett Learning.

Nursing Assessment When assessing which contraceptive method might meet the client’s needs, the nurse might ask the following: • Do your religious beliefs interfere with any methods? • Will this method interfere with your sexual pleasure? • Are you aware of the various methods currently available? • Is cost a major consideration, or does your insurance cover it? • Does your partner influence which method you choose? • Are you in a stable, monogamous relationship? • Have you heard anything troubling about any of the methods? • How comfortable are you touching your own body? • What are your future plans for having children? Although deciding on a contraceptive is a very personal decision between a woman and her partner, nurses can assist in this process by performing a complete health history and physical examination, and by educating the woman and her partner about necessary laboratory and diagnostic testing. Areas of focus during the nursing assessment are as follows: • Medical history: smoking status, cancer of reproductive tract, diabetes mellitus, migraines, hypertension, thromboembolic disorder, allergies, risk factors for cardiovascular disease (CVD) • Family history: cancer, CVD, hypertension, stroke, diabetes • OB/GYN history: menstrual disorders, current contraceptive, previous STIs, PID, vaginitis, sexual activity • Personal history: use of tampons and female hygiene products, plans for childbearing, comfort with touching herself, number of sexual partners and their involvement in the decision • Physical examination: height, weight, blood pressure, breast examination, thyroid palpation, pelvic examination • Diagnostic testing: urinalysis, complete blood count, Pap smear, wet mount to check for STIs, HIV/AIDS tests, lipid profile, glucose level

Figure 4.20 shows an example of a family planning flow record that can be used during the assessment. After collecting the assessment data above, consider the medical factors to help decide if the woman is a candidate for all methods or whether some should be eliminated. For example, if she reports she has multiple sex partners and a history of pelvic infections, she would not be a good candidate for an intrauterine contraceptive. Barrier methods (male or female condoms) of contraception might be recommended to this client to offer protection against STIs.

Nursing Diagnoses A few nursing diagnoses that might be appropriate based on the nurse’s assessment during the decision-making process include: • Deficient knowledge related to: • methods available • side effects/safety • correct use of method chosen • previous myths believed • Risk for infection related to: • unprotected sexual intercourse • past history of STIs • methods offering protection Nursing diagnoses applicable to the contraceptive would be: • Health-seeking behaviors related to: • perceived need for limiting number of children • overall health relative to contraceptives • Risk for ineffective health maintenance related to: • not being familiar with the various contraceptive methods • being unaware of high-risk sexual behavior leading to STIs • Fear related to: • not understanding the correct procedure to use • unintended pregnancy occurring if not used correctly • general health concerning the long-term side effects

Nursing Interventions Contraception is an important issue for all couples, and the method used should be decided by the woman and her partner jointly. Facilitate this process by establishing a trusting relationship with the client and by providing unbiased, accurate information about all methods available. As a nurse, reflect honestly on your feelings about contraceptives while allowing the client’s feelings to be paramount. Be aware of the practical issues involved in contraceptive use, and avoid making assumptions, making decisions on the woman’s behalf, and making judgments about her and her situation. To do so, it is important to keep up to date on the latest methods available and convey this information to clients. Encourage female clients to take control of their lives by sharing information that allows them to plan their futures. The following guidelines are helpful in counseling and educating the client or couple about contraceptives: • Encourage the client/couple to participate in choosing a method. • Provide client education. The client/couple must become informed users before the method is chosen. Education should be targeted to the client’s level so it is understood. Provide step-by-step teaching and an opportunity for practice for certain methods (cervical caps, diaphragms, vaginal rings, and condoms). See Teaching Guidelines 4.5 and Figure 4.21.

FIGURE 4.20 Family planning flow (visit) record.

FIGURE 4.21 The nurse demonstrates insertion of a vaginal ring during client teaching.

• Obtain written informed consents, which are needed for intrauterine contraceptives, implants, abortion, or sterilization. Informed consent implies that the client is making a knowledgeable, voluntary choice; has received complete information about the method, including the risks; and is free to change her mind before using the method or having the procedure (Schuiling & Likis, 2016). • Discuss contraindications for all selected contraceptives. • Consider the client’s cultural and religious beliefs when providing care. • Address myths and misperceptions about the methods under consideration in your initial discussion of contraceptives.

Teaching Guidelines 4.5

TIPS FOR THE USE OF CERVICAL CAPS, DIAPHRAGMS, VAGINAL RINGS, AND CONDOMS Cervical Cap Insertion/Removal Technique • It is important to be involved in the fitting process. • To insert the cap, pinch the sides together, compress the cap dome, insert into the vagina, and place over the cervix.

• Use one finger to feel around the entire circumference to make sure there are no gaps between the cap rim and the cervix. • After a minute or two, pinch the dome and tug gently to check for evidence of suction. The cap should resist the tug and not slide off easily. • To remove the cap, press the index finger against the rim and tip the cap slightly to break the suction. Gently pull out the cap. • The woman should practice inserting and removing the cervical cap three times to validate her proficiency with this device. Client Teaching and Counseling Regarding the Cervical Cap • Fill the dome of the cap up about one third full with spermicide cream or jelly. Do not apply spermicide to the rim, since it may interfere with the seal. • Wait approximately 30 minutes after insertion before engaging in sexual intercourse to be sure that a seal has formed between the rim and the cervix. • Leave the cervical cap in place for a minimum of 6 hours after sexual intercourse. It can be left in place for up to 48 hours without additional spermicide being added. • Do not use during menses due to the potential for toxic shock syndrome. Use an alternative method such as condoms during this time. • Replace the cervical cap after each year of use. • Inspect the cervical cap prior to insertion for cracks, holes, or tears. • After using the cervical cap, wash it with soap and water, dry thoroughly, and store in its container. Diaphragm Insertion/Removal Technique • Always empty the bladder prior to inserting the diaphragm. • Inspect diaphragm for holes or tears by holding it up to a light source, or fill it with water and check for a leak. • Place approximately a tablespoon of spermicidal jelly or cream in the dome and around the rim of the diaphragm. • The diaphragm can be inserted up to 6 hours prior to intercourse. • Select the position that is most comfortable for insertion: • Squatting

• Leg up, raising the nondominant leg up on a low stool • Reclining position, lying on back in bed • Sitting forward on the edge of a chair • Hold the diaphragm between the thumb and fingers and compress it to form a “figure-eight” shape. • Insert the diaphragm into the vagina, directing it downward as far as it will go. • Tuck the front rim of the diaphragm behind the pubic bone so that the rubber hugs the front wall of the vagina. • Feel for the cervix through the diaphragm to make sure it is properly placed. • To remove the diaphragm, insert the finger up and over the top side and move slightly to the side, breaking the suction. • Pull the diaphragm down and out of the vagina. Client Teaching and Counseling Regarding the Diaphragm • Avoid the use of oil-based products, such as baby oil, because they may weaken the rubber. • Wash the diaphragm with soap and water after use and dry thoroughly. • Place the diaphragm back into the storage case. • The diaphragm may need to be refitted after weight loss or gain or childbirth. • Diaphragms should not be used by women with latex allergies. Vaginal Ring Insertion/Removal Technique and Counseling • Each ring is used for one menstrual cycle, which consists of 3 weeks of continuous use followed by a ring-free week to allow for menses. • No fitting is necessary—one size fits all. • The ring is compressed and inserted into the vagina, behind the pubic bone, as far back as possible. • Precision placement is not essential. • Backup contraception is needed for 7 days if the ring is expelled for more than 3 hours during the 3-week period of continuous use. • The vaginal ring is left in place for 3 weeks, then removed and discarded.

• The vaginal ring is not recommended for women with uterine prolapse or lack of vaginal muscle tone (Schuiling & Likis, 2016). Male Condom Insertion/Removal Technique and Counseling • Always keep the condom in its original package until ready to use. • Store in a cool, dry place. • Spermicidal condoms should be used if available. • Check expiration date before using. • Use a new condom for each sexual act. • Condom is placed over the erect penis prior to insertion. • Place condom on the head of the penis and unroll it down the shaft. • Leave a half-inch of empty space at the end to collect ejaculate. • Avoid use of oil-based products, because they may cause breakage. • After intercourse, remove the condom while the penis is still erect. • Discard condom after use. Female Condom Insertion/Removal Technique and Counseling • Practice wearing and inserting prior to first use with sexual intercourse. • Condom can be inserted up to 8 hours before intercourse. • Condom is intended for one-time use. • It can be purchased over the counter—one size fits all. • Avoid wearing rings to prevent tears; long fingernails can also cause tears. • Spermicidal lubricant can be used if desired. • Insert the inner ring high in the vagina, against the cervix. • Place the outer ring on the outside of the vagina. • Make sure the erect penis is placed inside the female condom. • Remove the condom after intercourse. Avoid spilling the ejaculate. Education and Counseling of women using Injectable Contraceptives • Consume a diet high in calcium and vitamin D to prevent bone mineral loss. • Know the conditions that need to be reported to the health care provider: • Significant headaches • Menorrhagia

• Depression • Severe abdominal pain • Awareness of any infection present at injection site. It is also important to clear up common misconceptions about contraception and pregnancy. Clearing up misconceptions will permit new learning to take hold and a better client response to whichever methods are explored and ultimately selected. Some common misconceptions include: • Breast-feeding protects against pregnancy. • Pregnancy can be avoided if the male partner “pulls out” before he ejaculates. • Pregnancy cannot occur during menses. • Douching after sex will prevent pregnancy. • Pregnancy will not happen during the first sexual experience. • Taking birth control pills protects against STIs. • The woman is too old to get pregnant. • If female orgasm is not reached, conception is not likely. • Irregular menstruation prevents pregnancy. When discussing in detail each method of birth control, focus on specific information for each method outlined. Include information such as how this particular method works to prevent pregnancy under normal circumstances of use; the noncontraceptive benefits to overall health; advantages and disadvantages of all methods; the cost involved for each particular method; danger signs that need to be reported to the health care provider; and the required frequency of office visits needed for the particular method. In addition, outline factors that place the client at risk for method failure. Contraceptives can fail for any of many reasons. Use Table 4.6 to provide client education concerning a few of the reasons for contraceptive failure. Help clients who have chosen abstinence or fertility awareness methods to define the sexual activities in which they do or do not want to participate. This helps them set sexual limits or boundaries. Help them to develop communication and negotiation skills that will allow them to be successful. Supporting, encouraging, and respecting a couple’s choice of abstinence is vital for nurses.

TABLE 4.6 CONTRACEPTIVE PROBLEMS AND EDUCATIONAL NEEDS

After clients have chosen a method of contraception, it is important to address the following: • Emphasize that a second method to use as a backup is always needed. • Provide both oral and written instructions on the method chosen. • Discuss the need for STI protection if not using a barrier method. • Inform the client about the availability of ECs. Steady progress in contraception research has been achieved over the past several years. Hormonal and nonhormonal contraceptives have improved women’s lives by reducing different health conditions that contribute to morbidity. However, the contraceptives available today are not suitable to all users, and the need to expand contraceptive choices still exists. It is hoped that the introduction of newer methods in the near future with additional health benefits will continue to help women and couples meet their family planning needs.

ABORTION Abortion is defined as the expulsion of an embryo or fetus before it is viable (Alexander et al., 2014). Abortion can be a medical or surgical procedure. The purpose of abortion is to terminate a pregnancy. More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives. Both in the United States and globally, more than one fifth of all known pregnancies end in abortion (McFarlane, 2015). Surgical abortion is the most common procedure performed in the United States (approximately 1.3 million annually) and might be the most common surgical procedure in the world (Alan Guttmacher Institute, 2015b). Both medical and surgical abortions are safe and legal in the United States; an abortion is considered a woman’s constitutional right based on the fundamental right to privacy. Eighty-nine percent of abortions occur in the first 12 weeks of pregnancy (Alan Guttmacher Institute, 2015b). Since the landmark U.S. Supreme Court decision Roe v. Wade legalized abortion in 1973, debate has continued over how and when abortions are provided. Every state has laws regulating some aspects of the provision of abortion, and many have passed restrictions such as parental consent or notification requirements, mandated counseling and waiting periods, and limits on funding for abortion. Each state addresses these matters independently, and the laws that are passed or enforced are legislative decisions and a function of the political system. Although opponents of abortion continue to be very much a part of the current debates, recently they have refocused their attention on “regulation legislation” among the states to reduce the number of abortions not medically necessary (Kreitzer, 2015).

Surgical Abortion Two types of surgical abortion are available: vacuum aspiration or dilation, and evacuation (D&C). Method selection is based on gestational age. It is an ambulatory procedure done under local anesthesia. The cervix is dilated prior to surgery and then the products of conception are removed by suction evacuation. The uterus may gently be scraped by curettage to make sure that it is empty. The entire procedure lasts about 10 minutes. The overall risk of complications is less than 1% for surgical termination (Upadhyay et al., 2015).The major risks and complications in the first trimester are infection, retained tissue or hemorrhage, uterine perforation, retained products of conception, or cervical tear (Udoh et al., 2015). For women whose blood is Rh negative, RhoGAM is indicated prior to start of either medical or surgical termination.

Medical Abortion Medical abortions are achieved through administration of medication either vaginally or orally. The administration of medication occurs in the clinic or doctor’s office, may require two to four office visits, and costs between $300 and $800 (Planned Parenthood, 2015b). Three drugs are currently used to terminate a pregnancy during the first trimester. The first drug is methotrexate (an antineoplastic agent; Rheumatrex) followed by misoprostol (a prostaglandin agent; Cytotec) given as a vaginal suppository or in oral form 3 to 7 days later. Methotrexate induces abortion because of its toxicity to trophoblastic tissue, the growing embryo. Misoprostol works by causing uterine contractions, which helps to expel the products of conception. This method is 90% to 98% successful in completing an abortion (Patil & Edelman, 2015). The second drug used to induce first-trimester abortions involves using mifepristone (a progesterone antagonist; Mifeprex, RU-486) followed 48 hours later by misoprostol (a prostaglandin agent), which causes contractions of the uterus and expulsion of the uterine contents. Currently, the most widely used method of medication abortion in the United States is the administration of mifepristone in conjunction with misoprostol. Another frequent method used includes the combination of methotrexate with misoprostol (Schuiling & Likis, 2016). Mifepristone, the generic name for RU-486, is sold under the brand names Mifeprex and Early Option. Mifepristone is an antiprogestin and blocks the action of progesterone, which is necessary for the maintenance of the pregnancy. This method is 95% effective when used within 49 days after the last menstrual cycle (Patil & Edelman, 2015). Another drug frequently used is misoprostol (Cytotec), which is a prostaglandin analog that softens the cervix and causes uterine contractions, which results in the expulsion of uterine contents. There is no standard protocol for use of misoprostol (Cytotec) alone for termination of early pregnancy, and it is not FDA-approved for this purpose (King et al., 2015). Complications of medical abortions include incomplete expulsion of uterine contents, uterine infection, and heavy bleeding (Ganatra, Guest, & Berer, 2015). The assessment of the woman with an unintended pregnancy should be performed with cautious sensitivity. It is essential to explore the women’s feelings about pregnancy before congratulating or consoling her. The encounter should be guided by the feelings of the client, not by the assumptions and values

of the nurse. Abortion is a very emotional, deeply personal issue. Give support and accurate information. If for personal, religious, or ethical reasons you feel unable to actively participate in the care of a woman undergoing an abortion, you still have the professional responsibility to ensure that the woman receives the nursing care and help she requires. This may necessitate a transfer to another area or a staffing reassignment. Nurses must keep in mind that all women have the right to have access to unbiased, factual information about available reproductive health choices, whether they seek to end or start a pregnancy, from which they can then make informed decisions about their own reproductive health.

MENOPAUSAL TRANSITION Menopause is a natural process that occurs in all women’s lives as part of normal aging. Meno is derived from the Greek word for “month,” and pause is derived from the Greek word for “pause” or “halt.” Menopause is the technical term for a point in time at which menses and fertility cease (King et al., 2015). The change of life. The end of fertility. The beginning of freedom. Whatever people call it, menopause is a unique and personal experience for every woman. The term menopausal transition refers to the transition from a woman’s reproductive phase of her life to her final menstrual period. This period is also referred to as perimenopause. It is the end of her menstruation and childbearing capacity. The average age of natural menopause—defined as 1 year without a menstrual period—is 51.4 years old. The average age of natural menopause has remained constant for the last several hundred years despite improvements in nutrition and health care (Alexander et al., 2014). With current female life expectancy at 84 years, this event comes in the middle of a woman’s adult life. Many women go through the menopausal transition with few or no symptoms, while some have significant or even disabling symptoms.

Take Note! Humans are virtually the only species to outlive their reproductive capacities. Menopause signals the end of an era for many women. It concludes their ability to reproduce, and some women find advancing age, altered roles, and these physiologic changes to be overwhelming events that may precipitate depression and anxiety (Woods & Mitchell, 2015). Menopause does not happen in isolation. Midlife is often experienced as a time of change and reflection. Change happens in many arenas: children are leaving or returning home, employment pressures intensify as career moves or decisions are required, older adult parents require more care or the death of a parent may have a major impact, and partners are retrenching or undergoing their own midlife crises. Women must negotiate all these changes in addition to menopause. Managing these stressful changes can be very challenging for many women as they make

the transition into midlife. A woman is born with approximately 2 million ova, but only about 400 ever mature fully to be released during the menstrual cycle. The absolute number of ova in the ovary is a major determinant of fertility. Over the course of her premenopausal life there is a steady decline in the number of immature ova (Wood, 2015). No one understands this depletion, but it does not occur in isolation. Maturing ova are surrounded by follicles that produce two major hormones: estrogen, in the form of estradiol, and progesterone. The cyclic maturation of the ovum is directed by the hypothalamus. The hypothalamus triggers a cascade of neurohormones, which act through the pituitary and the ovaries as a pulse generator for reproduction. This hypothalamic–pituitary– ovarian axis begins to break down long before there is any sign that menopause is imminent. Some scientists believe that the pulse generator in the hypothalamus simply degenerates; others speculate that the ovary becomes more resistant to the pituitary hormone FSH and simply shuts down (Schuiling & Likis, 2016). The final act in this well-orchestrated process is amenorrhea. As menopause approaches, more and more of the menstrual cycles become anovulatory. This period of time, usually 2 to 8 years before cessation of menstruation, is termed perimenopause (McNamara, Batur, & DeSapri, 2015). In perimenopause, the ovaries begin to fail, producing irregular and missed periods and an occasional hot flash. When menopause finally appears, viable ova are gone. Estrogen levels plummet by 90%, and estrone, produced in fat cells, replaces estradiol as the body’s main form of estrogen. The major hormone produced by the ovaries during the reproductive years is estradiol; the estrogen found in postmenopausal women is estrone. Estradiol is much more biologically active than estrone (Hoyt & Falconi, 2015). In addition, testosterone levels decrease with menopause. Menopausal transition, with its dramatic decline in estrogen, affects not only the reproductive organs, but also other body systems: • Brain: hot flashes, disturbed sleep, mood and memory problems • Cardiovascular: lower levels of high-density lipoprotein (HDL) and increased risk of CVD • Skeletal: rapid loss of bone density that increases the risk of osteoporosis • Breasts: replacement of duct and glandular tissues by fat • Genitourinary: vaginal dryness, stress incontinence, cystitis • Gastrointestinal: less absorption of calcium from food, increasing the risk for

fractures • Integumentary: dry, thin skin and decreased collagen levels • Body shape: more abdominal fat; waist size that swells relative to hips

Therapeutic Management Menopausal transition should be managed individually. In the past, despite the wide diversity of symptoms and risks, the traditional reaction was to reach for the one-size-fits-all therapy: HT. Today the medical community is changing its thinking in light of the Women’s Health Initiative (WHI) study and the Heart and Estrogen/Progestin Replacement Study Follow-Up (HERS II), which reported that long-term HT increased the risks of heart attacks, strokes, and breast cancer; in short, the overall health risks of HT exceeded the benefits (Kyvernitakis et al., 2015). In addition, HT did not protect against the development of coronary artery disease (CAD), nor did it prevent the progression of CAD, as it was previously touted to do. A recent research finding examined the timing of HT in relation to CAD in women and it found that the earlier initiation of HT was associated with less CAD in women with natural but not surgical menopause. A Cochrane Review study found that HT in postmenopausal women overall, had little benefit in CAD prevention, but caused an increase in the risk of stroke and venous thromboembolic events (Boardman et al., 2015). As expected, the fallout from this study and others forced practitioners to re-evaluate their usual therapies and tailor treatment to each client’s history, needs, and risk factors. A current study, however, shows that the incidence of fractures among menopausal transition and postmenopausal women increased significantly in the 3 years after publication of the WHI and HERS II results. This trend followed a decline in the use of HT, concurrent with an increase in the use of other bone-modifying agents (Bakour & Williamson, 2015). There is considerable evidence that estrogen or HT reduces the risk of postmenopausal osteoporotic fracture of both the spine and hip (Mirkin et al., 2015). A number of treatment options are available, but factors in the client’s history should be the driving force when determining therapy. Women need to educate themselves about the latest research findings and collaborate with their health care provider on the right menopause therapy. The following factors should be considered in management: • The risk/benefit ratio is highest in younger women who begin HT not long after menopause. • HT is approved for two indications: relief of vasomotor symptoms and

prevention of osteoporosis. • Research suggests that HT may be beneficial for preventing diabetes, improving mood, or avoiding urinary tract problems. • Using HT long beyond menopause carries increased risks, which, for some women, may be outweighed by the benefits (Bakour & Williamson, 2015). Many women consider nonhormonal therapies such as bisphosphonates and selective estrogen receptor modulators (SERMs). Consider weight-bearing exercises, calcium, vitamin D, smoking cessation, and avoidance of alcohol to treat or prevent osteoporosis. Annual breast examinations and mammograms are essential. Local estrogen creams can be used for vaginal atrophy. Consider herbal therapies for symptoms, although none have been validated by rigorous research studies (Ismail et al., 2015). ACOG recently revised guidelines on treating menopausal symptoms. Their recommendations include systemic HT, with estrogen or estrogen plus progestin, is the most effective approach for treating vasomotor symptoms; the lowest effective dose for the shortest duration is the best regimen; thromboembolic disease and breast cancer are risks for combined systemic HT; and local estrogen therapy is advised for isolated atrophic vaginal symptoms (2014). Although numerous symptoms have been attributed to menopause (Box 4.9), some of them are more closely related to the aging process than to estrogen deficiency. A few of the more common menopausal conditions and their management are discussed next.

Managing Hot Flashes and Night Sweats The emergence of hot flashes and night sweats (also known as vasomotor symptoms) coincides with a period in life that is also marked by dynamic changes in hormone and reproductive function that interconnect with the aging process, changes in metabolism, lifestyle behaviors, and overall health (Wood, 2015). Hot flashes and night sweats are classic signs of estrogen deficiency and the predominant complaint of perimenopausal women. A hot flash is a transient and sudden sensation of warmth that spreads over the body, particularly the neck, face, and chest. Hot flashes are caused by vasomotor instability. This instability causes inappropriate peripheral vasodilation of superficial blood vessels, which gives the sensation of heat. Nearly 85% of menopausal women experience them (Alexander et al., 2014). Hot flashes are an early and acute sign

of estrogen deficiency. These flashes can be mild or extreme and can last from 2 to 30 minutes and may occur as frequently as every hour to several times per week. On average, women experience hot flashes for a period of 6 months to 2 years, but the symptoms may last up to 10 years or more. Severe vasomotor symptoms can have a significant and detrimental effect on quality of life. Factors that trigger vasomotor symptoms include caffeine and alcohol consumption, intake of hot drinks and spicy foods, hot environment, depression, stress, and anxiety (Avis et al., 2015).

BOX 4.9 COMMON SYMPTOMS OF MENOPAUSE • Hot flashes or flushes of the head and neck • Dryness in the eyes and vagina • Personality changes • Anxiety and/or depression • Loss of libido • Decreased lubrication • Weight gain and water retention • Night sweats • Atrophic changes—loss of elasticity of vaginal tissues • Fatigue • Irritability • Poor self-esteem • Insomnia • Stress incontinence • Heart palpitations Adapted

from

Coney,

P.

(2015).

Menopause.

Emedicine.

Retrieved

from

http://emedicine.medscape.com/article/264088-overview; Kessenich, C. R. (2015). Inevitable menopause. Nursing Spectrum. Retrieved from http://ce.nurse.com/ce232-60/Inevitable-Menopause; and Schuiling, K. D. & Likis, F. E. (2016). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Many options are available for treating hot flashes. Treatment must be based on symptom severity, the client’s medical history, and the client’s values and concerns. Although the gold standard in the treatment of hot flashes is estrogen, this is not recommended for all women who have high risk factors in their history.

TRADITIONAL THERAPIES FOR THE MANAGEMENT OF HOT FLASHES The following are traditional therapies for the management of hot flashes: • Pharmacologic options • HT unless contraindicated • Androgen therapy (potentiates estrogen) • Estrogen and androgen combinations • Progestin therapy (Depo-Provera injection every 3 months) • Clonidine (central alpha-adrenergic agonist) weekly patch • Neurontin (antiseizure) decreased hot flashes • Propranolol (beta-adrenergic blocker) • Brisdelle: FDA approved nonhormonal medication • Short-term sleep aids: Ambien, Dalmane • Gabapentin (Neurontin): antiseizure drug • SSRIs: venlafaxine (Effexor) and paroxetine (Paxil) have shown promise (King & Brucker, 2016) COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR MANAGEMENT OF HOT FLASHES Many women are choosing alternative treatments for managing menopausal symptoms. Bioidentical hormones have the ability to bind to receptors in the human body and function in the same way as a woman’s natural hormones. They simulate three estrogens (estradiol, estriol, and estrone), as well as progesterone, testosterone, dehydroepiandrosterone (DHEA), thyroxine, and cortisol. Bioidentical hormones are not, however, natural hormones. The estrogens are derived via a chemical process from soybeans (Glycine max) and progesterone from Mexican yam (dioscorea villosa). As with conventional hormones, however, bioidentical hormones are available only with a physician’s prescription and through a pharmacy. Because of their natural origin, women perceive that alternative treatments are safer. The interest in phytoestrogens came about because of the low prevalence of hot flashes in Asian women, which was attributed to their diet being rich in phytoestrogens. Recent studies have found that black cohosh, multibotanical herbs, and increased soy intake do not reduce the frequency or severity of menopausal hot flashes or night sweats.

Other remedies for easing menopausal symptoms might include red clover, motherwort, ginseng, sarsaparilla root, valerian root, L-tryptophan, calciummagnesium, and kelp tablets (Ismail et al., 2015). Again, research thus far has been skeptical about their efficacy, but many women report they ease their symptoms and their use has skyrocketed. Although some benefits may accrue from their use, evidence of the efficacy of alternative products in menopause is largely anecdotal. Small, preliminary clinical trials might demonstrate the safety of some of the nonpharmacologic products. Nurses should be aware of the purported action of these agents as well as any adverse effects or drug interactions. The following are lifestyle changes and CAM therapies for the treatment of hot flashes: • Lifestyle changes • Lower room temperature; use fans • Wear clothing in layers for easy removal • Limit caffeine and alcohol intake • Drink 8 to 10 glasses of water daily • Stop smoking or cut back • Avoid hot drinks and spicy food • Take calcium (1,200 to 1,600 mg) and vitamin D (400 to 600 International Units) • Exercise daily, but not just before bedtime • Maintain a healthy weight • Identify stressors and learn to manage them • Keep a diary to identify triggers of hot flashes • Phytoestrogens: isoflavones, ligands, coumetrols • Black cohosh • Chamomile: mild sedative to alleviate insomnia • Unopposed transdermal progesterone • Compounded bioidentical hormones • Try relaxation techniques, deep breathing, and meditation • Acupuncture may reduce the frequency of hot flashes

• Vitamin E: 100 mg daily • Dehydroepiandrosterone (DHEA) • Chaste tree berry (vitex): balances progesterone and estrogen • Dong quai: acts as a form of phytoestrogen • Ginseng: purported to improve memory • St. John’s wort: reduces depression and fatigue • Wild yam: treats menopausal symptoms • Valerian root: induces sleep and relaxation (Wood, 2015)

Managing Urogenital Changes Menopausal transition can be a physically and emotionally challenging time for women. In addition to the psychological burden of leaving behind the reproductive phase of life and the stigma of an aging body, sexual difficulties resulting from urogenital changes plague most women but are frequently not addressed. Sexual desire is affected by endocrine and psychosocial factors. Menopausal hormonal changes are relevant to the causes of sexual dysfunction during reproductive aging. The frequency of sexual intercourse declines as women enter midlife. Whereas partner availability and function probably play a role, menopausal symptoms, such as vaginal dryness, are also present (Comhaire & Depypere, 2015). Vaginal atrophy occurs during menopause because of declining estrogen levels. These changes include thinning of the vaginal walls, an increase in pH, irritation, increased susceptibility to infection, dyspareunia (difficult or painful sexual intercourse), loss of lubrication with intercourse, vaginal dryness, and a decrease in sexual desire related to these changes. Decreased estrogen levels can also influence a woman’s sexual function as well. Delayed clitoral reaction, decreased vaginal lubrication, diminished circulatory response during sexual stimulation, and reduced contractions during orgasm have all been linked to low estrogen levels (Coney, 2015). Management of these changes might include the use of estrogen vaginal tablets (Vagifem) or Premarin cream; Estring, an estrogen-releasing vaginal ring that lasts for months; testosterone patches; and over-the-counter moisturizers and lubricants (Astroglide) (King et al., 2015). A positive outlook on sexuality and a supportive partner are also needed to make the sexual experience enjoyable and fulfilling. Nurses can improve the sexual health and quality of life in menopausal

women by educating them about their symptoms and offering them choices about managing them.

Take Note! Sexual health is an important aspect of the human experience. By keeping an open mind, listening to women, and providing evidence-based treatment options, the nurse can help improve quality of life for menopausal women.

Preventing and Managing Osteoporosis Osteoporosis has been recognized as a significant worldwide public health problem. As the world’s population ages, both in the United States and internationally, the prevalence of osteoporosis is expected to increase significantly. Osteoporosis is the state of diminished bone density. This disorder is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture (National Osteoporosis Foundation [(NOF], 2015a). According to recent information from NOF (2015a), osteoporosis is a major medical problem that affects 10 million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated 1.5 million individuals in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of ∃18 billion. By 2025, experts predict that osteoporosis will be responsible for approximately 3 million fractures and ∃26 billion in costs each year (NOF, 2015a). With the rapidly aging population, the problem of osteoporosis is now reaching epidemic proportions. Seventy-five million baby boomers are entering the stage in their lives when they are most at risk for osteoporosis. One half of all women and one third of all men will sustain a fragility fracture during their lifetimes. Osteoporosis continues to be underdiagnosed and undertreated because it is often not recognized until the first fracture occurs. Women are greatly affected by osteoporosis after menopause. Osteoporosis is a condition in which bone mass declines to such an extent that fractures occur with minimal trauma. Bone loss begins in the third or fourth decade of a woman’s life and accelerates rapidly after menopause (Alexander et al., 2014).

This condition puts many women into long-term care, with a resulting loss of independence. Figure 4.22 shows the skeletal changes associated with osteoporosis.

FIGURE 4.22 Skeletal changes associated with osteoporosis. (John Radcliffe Hospital/Photo Researcher Inc.)

Most women with osteoporosis do not know they have the disease until they sustain a fracture, usually of the wrist or hip. Risk factors include: • Increasing age • Postmenopausal status without hormone replacement • Small, thin-boned frame • Low bone mineral density • White or Asian with small bone frame • Impaired eyesight that would increase risk of falling • Rheumatoid arthritis • Family history of osteoporosis • Sedentary lifestyle • History of treatment with:

• Antacids with aluminum • Heparin • Long-term use of steroids > 3 months • Thyroid replacement drugs • Smoking and consuming alcohol • Low calcium and vitamin D intake • Excessive amounts of caffeine • Personal history of nontraumatic fracture • Anorexia nervosa or bulimia (NOF, 2015a) Currently, no method exists for directly measuring bone mass. Instead a BMD measurement is used. BMD is a two-dimensional measurement of the average content of mineral in a section of bone. BMD evaluations are made at the hip, femoral neck, and spine. There is a significant relationship between BMD and fracture: as BMD is reduced, the risk of fracture increases (Sullivan et al., 2015). Screening tests to measure bone density are not good predictors for young women who might be at risk for developing this condition. Dual-energy x-ray absorptiometry (DXA or DEXA) is a screening test that calculates the mineral content of the bone at the spine and hip. It is highly accurate, fast, and relatively inexpensive. The dual energy x-ray absorptiometry scan (DEXA scan) is the gold standard radiologic method for identifying osteoporosis through measuring BMD (U.S. Preventive Services Task Force, 2015). Hip fracture is the most devastating of the fragility fractures secondary to osteoporosis. A number of medical, social, and economic consequences follow a hip fracture. Of women older than 50 years, on average, 24% die within the first year after hip fracture (Wang et al., 2015). The concern surrounding osteoporosis is not the rate of fracture alone but also the potential for lifelong disability secondary to fracture. The incidence of hip fracture is estimated to double by the year 2025 and nearly double again by 2050. For women, this is a projected 240% increase (NOF, 2015a). The best management for this painful, crippling, and potentially fatal disease is prevention. Women can modify many risk factors by doing the following: • Engage in daily weight-bearing exercise, such as walking to increase osteoblast activity.

• Increase calcium and vitamin D intake. • Avoid smoking and excessive alcohol (more than two drinks per day). • Discuss bone health with a health care provider. • When appropriate, have a bone density test and take medication if needed (NOF, 2015b). Medications that can help in preventing and managing osteoporosis include: • HT (Premarin) • SERMs (raloxifene [Evista]) • Calcium and vitamin D supplements (Tums) • Estrogen agonist/antagonist [SERM] (Evista) • Bisphosphonates (Actonel, Fosamax, Boniva, or Reclast) • Parathyroid hormone (Forteo) • Calcitonin (Miacalcin) (King & Brucker, 2016)

Preventing and Managing Cardiovascular Disease Despite the dramatic decrease in annual CVD mortality and total cardiovascular mortality for American women each year since 2000, CVD remains the numberone killer of women, accounting for one in three deaths in the United States. This is likely due to increased rates of obesity, sedentary lifestyle, diabetes, and high cholesterol levels (Chomistek et al., 2015). More women die from heart disease and stroke than the next five causes of death combined, including breast cancer. Half a million women die annually in the United States of CVD, with strokes accounting for about 20% of the deaths (Alexander et al., 2014). This translates into approximately one death every minute. While men’s mortality from CVD has decreased since the 1980s, women’s mortality from CVD has climbed. This has resulted in a sex-related CVD mortality gap, with women having higher mortality than men since 1984. Contributing to this femalemajority CVD mortality gap is a lack of awareness among women and their physicians of the risk for CVD. Awareness campaigns, such as the Heart Truth and the Red Dress symbol, appear to have improved recognition of CVD risk in women. Further, female-specific guidelines have been developed to prevent and reduce CVD in women. Though the current understanding of the role of menopause in CVD is controversial, studies suggest that menopause does not

exacerbate CVD independent of aging, and HT is not effective for secondary prevention of CVD (Hale & Shufelt, 2015). For the first half of a woman’s life, estrogen seems to be a protective substance for the cardiovascular system by smoothing, relaxing, and dilating blood vessels. It even helps boost HDL and lower low-density lipoprotein (LDL) levels, helping to keep the arteries clean from plaque accumulation. But when estrogen levels plummet as women age and experience menopause, the incidence of CVD increases dramatically. Women are more likely to have atypical cardiovascular symptoms compared with men. This may lead to a delayed or misdiagnosis of CAD and suboptimal treatment. These symptoms may include: • A – Angina (chest pain) • B – Breathlessness • C – Chronic fatigue • D – Dizziness • E – Edema of hands and feet • F – Fluttering of the heart • G – Gastric upset • H – Heavy pain in back and shoulders Menopause is not the only factor that increases a woman’s risk for CVD. Lifestyle and medical history factors such as the following play a major role: • Smoking • Obesity • High-fat diet • Sedentary lifestyle • High cholesterol levels • Family history of CVD • Hypertension • Apple-shaped body • Diabetes Two of the major risk factors for coronary heart disease are hypertension and

dyslipidemia. Both are modifiable and can be prevented by lifestyle changes and, if needed, controlled by medication. This is why prevention is essential. In addition, women who experience early menopause lose the protection afforded by endogenous estrogen to the cardiac system and are at greater risk for more extensive atherosclerosis. Major preventive strategies include a healthy diet, increased activity, exercise, smoking cessation, decreased alcohol intake, and weight reduction. Nurses, particularly those caring for women during their reproductive years, are uniquely positioned to provide education and support for women’s long-term cardiovascular health. Raising awareness of heart disease in women is an essential role for nurses. The good news is that CVD is largely preventable. Because CVD is a chronic disease that develops over time, primary prevention lifestyle modification interventions are most effective if initiated before the development of overt disease. Stressing the importance of lifestyle modifications must begin early in life and should be reinforced from the beginning of a young woman’s reproductive years through menopause. Nurses are in an ideal position to teach the importance of good nutrition, healthy weight, and daily exercise before CVD becomes clinically evident.

Nursing Assessment Menopausal transition is a universal and irreversible part of the overall aging process involving a woman’s reproductive system. Although not a disease state, menopausal transition does place women at greater risk for the development of many conditions of aging. Nurses can help the woman become aware of her risk for postmenopausal diseases, as well as strategies to prevent them. The nurse can be instrumental in assessing risk factors and planning interventions in collaboration with the client. These might include: • Screening for osteoporosis, CVD, and cancer risk • Assessment of blood pressure to identify hypertension • Blood cholesterol test to identify hyperlipidemia risk • Mammogram to find a cancerous lesion • Pap smear to identify cervical cancer • Pelvic examination to identify endometrial cancer or masses • Digital rectal examination to assess for colon cancer • Bone density testing as a baseline at menopause to identify osteopenia (low bone mass), which might lead to osteoporosis • Assessing lifestyle to plan strategies to prevent chronic conditions: • Dietary intake of fat, cholesterol, and sodium • Weight management • Calcium intake • Use of tobacco, alcohol, and caffeine • Amount and type of daily exercise routines

Nursing Management There is no “magic bullet” in managing menopause. Nurses can counsel women about their risks and help them to prevent disease and debilitating conditions with specific health maintenance education. Women should make their own decisions, but the nurse should make sure they are armed with the facts to do so intelligently. Nurses can offer a thorough explanation of the menopausal process, including the latest research findings, to help women understand and make decisions about this inevitable event. If the woman decides to use HT to control her menopausal symptoms, after being thoroughly educated, she will need frequent reassessment. There are no hard-and-fast rules that apply to meeting a woman’s individual needs. The nurse can provide realistic expectations of the therapy to reduce the woman’s anxiety and concern. It is also useful to emphasize the value of friends to gain support and share information and resources. Often just talking about emotional difficulties such as the death of a parent or problematic relationships helps solve problems. It also shows the woman that her emotional responses are valid. Healthy lifestyles and stress management techniques are vital to health and longevity, and it is important to keep these on the client’s agenda when discussing menopause (North American Menopause Society, 2015). Evidencebased interventions include lifestyle modifications, risk management therapies, and preventive drug interventions, such as the following: • Participate actively in maintaining health. • Exercise regularly to prevent CVD and osteoporosis. • Take supplemental calcium and eat appropriately to prevent osteoporosis. • Stop smoking to prevent lung and heart disease. • Reduce caffeine and alcohol intake to prevent osteoporosis. • Monitor blood pressure, lipids, and diabetes (drug therapy management). • Use low-dose aspirin to prevent blood clots. • Reduce dietary intake of fat, cholesterol, and sodium to prevent CVD. • Maintain a healthy weight for body frame. • Perform breast self-examinations for breast awareness.

• Control stress to prevent depression (Worel & Hayman, 2015). These life approaches may seem low-tech, but they can stave off menopauserelated complications such as CVD, osteoporosis, and depression. These tips for healthy living work well, but the client needs to be motivated to stick with them. KEY CONCEPTS Establishing good health habits and avoiding risky behaviors early in life will prevent chronic conditions later in life. PMS has more than 150 symptoms, and at least 2 different syndromes have been recognized: PMS and PMDD. Endometriosis is a condition in which bits of functioning endometrial tissue are located outside their normal site, the uterine cavity. Infertility is a widespread problem that has an emotional, social, and economic impact on couples. More than half of all unintended pregnancies occur in women who report using some method of birth control during the month of conception. Hormonal methods include OCs, injectables, implants, vaginal rings, and transdermal patches. Recent studies have shown that the extension of active extended cycle OC pills carries the same safety profile as the conventional 28-day regimens (Zieman, 2015). Currently three intrauterine contraceptives are available in the United States: the copper ParaGard-TCu-380A, the levonorgestrel-releasing intrauterine system (LNG-IUS) marketed as Mirena and another LNG-IUD marketed as Skyla (King et al., 2015). OCs, sterilization, and male condoms are the most popular methods of contraception in the United States and worldwide (Alan Guttmacher Institute, 2015a). Menopause, with a dramatic decline in estrogen levels, affects not only the reproductive organs but also other body systems. Most women with osteoporosis do not know they have the disease until they sustain a fracture, usually of the wrist or hip (NOF, 2015a). Half a million women die annually in the United States of CVDs, with strokes

accounting for about 20% of the deaths (Alexander et al., 2014). Nurses should aim to have a holistic approach to the sexual health of women from menarche through menopause.

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CHAPTER WORKSHEET MULTIPLE-CHOICE QUESTIONS 1. A couple is considered infertile after how many months of trying to conceive? a. 6 months b. 12 months c. 18 months d. 24 months 2. A couple reports that their condom broke while they were having sexual intercourse last night. What would you advise to prevent pregnancy? a. Inject a spermicidal agent into the woman’s vagina immediately. b. Obtain emergency contraceptives and take them immediately. c. Douche with a solution of vinegar and hot water tonight. d. Take a strong laxative now and again at bedtime. 3. Which of the following combination contraceptives has been approved for extended continuous use? a. Seasonale b. Triphasil c. Ortho Evra d. Mirena 4. Which of the following measures helps prevent osteoporosis? a. Supplementing with iron

b. Sleeping 8 hours nightly c. Eating lean meats only d. Walking daily 5. Which of the following activities will increase a woman’s risk of cardiovascular disease if she is taking oral contraceptives? a. Eating a high-fiber diet b. Smoking cigarettes c. Taking daily multivitamins d. Drinking alcohol 6. The nurse is preparing to teach a class to a group of middle aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Which of the following would be a vasomotor symptom experienced by menopausal women? a. Weight gain b. Bone density c. Hot flashes d. Heart disease 7. Throughout life, a woman’s most proactive activity to promote her health would be to engage in: a. consistent exercise b. socialization with friends c. quality quiet time with herself d. consuming water 8. What comment by a woman would indicate that a diaphragm is not the best contraceptive device for her? a. “My husband says it is my job to keep from getting pregnant.” b. “I have a hard time remembering to take my vitamins daily.” c. “Hormones cause cancer and I don’t want to take them.”

d. “I am not comfortable touching myself down there.” 9. The most common cause of menstrual abnormality in a reproductive-age woman is: a. ectopic pregnancy b. coagulopathy c. carcinoma d. anovulation

CRITICAL THINKING EXERCISE 1. Ms. London, age 25, comes to your family planning clinic requesting to have an IUC inserted because “birth control pills give you cancer.” In reviewing her history, you note she has been into the STI clinic three times in the past year with vaginal infections and was hospitalized for PID last month. When you question her about her sexual history, she reports having sex with multiple partners and not always using protection. a. Is an IUC the most appropriate method for her? Why or why not? b. What myths/misperceptions will you address in your counseling session? c. Outline the safer sex discussion you plan to have with her.

STUDY ACTIVITIES 1. Develop a teaching plan for an adolescent with PMS and dysmenorrhea. 2. Arrange to shadow a nurse working in family planning for the morning. What questions does the nurse ask to ascertain the kind of family planning method that is right for each woman? What teaching goes along with each method? What follow-up care is needed? Share your findings with your classmates during a clinical conference. 3. Surf the Internet and locate three resources for infertile couples to consult that provide support and resources. 4. Sterilization is the most prevalent method of contraception used by married couples in the United States. Contact a local urologist and gynecologist to

learn about the procedure involved and the cost of a male and female sterilization. Which procedure poses less risk to the person and costs less? 5. Take a field trip to a local drugstore to check out the variety and costs of male and female condoms. How many different brands did you find? What was the range of costs? 6. Noncontraceptive benefits of combined oral contraceptives include which of the following? Select all that apply. a. Protection against ovarian cancer b. Protection against endometrial cancer c. Protection against breast cancer d. Reduction in incidence of ectopic pregnancy e. Prevention of functional ovarian cysts f. Reduction in deep venous thrombosis g. Reduction in the risk of colorectal cancer

BRINGING IT ALL TOGETHER: CASE STUDY L. H. is a 66-year-old White female who presents to the Women’s Health Primary Care Clinic for her annual gynecologic examination. She states that she is fairly healthy with no active medical conditions other than hypertension controlled with medication. She is postmenopausal and feels she is doing well, but has a few questions and concerns. Her primary concern is that she is bothered by vaginal dryness and pain with sexual intercourse. Over-the-counter lubricants and moisturizers have not been useful. She never took HT since her hot flashes were not severe, but asks if she should start taking it now to reduce her vaginal dryness. Go to

to find questions to consider about this case.

5 Sexually Transmitted Infections

KEY TERMS bacterial vaginosis genital/vulvovaginal candidiasis gonorrhea pelvic inflammatory disease (PID) sexually transmitted infection (STI) syphilis trichomoniasis

Learning Objectives Upon completion of the chapter, you will be able to: 1. Evaluate the spread and control of sexually transmitted infections. 2. Identify risk factors and outline appropriate client education needed in common sexually transmitted infections. 3. Describe how contraceptives can play a role in the prevention of sexually transmitted infections. 4. Analyze the physiologic and psychological aspects of sexually transmitted infections. 5. Outline the nursing management needed for women with sexually transmitted infections. Sandy, a 19-year-old girl, couldn’t imagine what these “things” were that appeared “down there” in her genital area last week. She was too embarrassed to tell anyone, so she stopped by the college health service today to find out what they were.

Words of Wisdom Unconditional self-acceptance in clients is the core to reducing risky behavior and fostering peace of mind.

INTRODUCTION Sexually transmitted infections (STIs) are infections of the reproductive tract caused by microorganisms transmitted through vaginal, anal, or oral sexual intercourse (Centers for Disease Control and Prevention [CDC], 2015a). STIs are a significant health challenge globally which pose a serious threat not only to women’s sexual health but also to the general health and well-being of millions of people worldwide (see Box 5.1 for STI classification). STIs constitute an epidemic of tremendous magnitude. An estimated 65 million people live with an incurable STI, 18,000 die from acquired immune deficiency syndrome (AIDS) annually, and another 20 million are newly infected each year (CDC, 2015a). The incidence of STIs continues to rise and costs the United States over $18 billion annually (CDC, 2015a). STIs are biologically sexist, presenting greater risk and causing more complications among women than among men. Women are diagnosed with two thirds of the estimated 20 million new cases of STIs annually in the United States. After only a single exposure, women are twice as likely as men to acquire infections from pathogens that cause gonorrhea, chlamydial infection, hepatitis B, and syphilis. Every day, more than one million people are newly infected with STIs that can lead to morbidity, mortality, and an increased risk of human immunodeficiency virus (HIV) acquisition (Fernández-Romero et al., 2015). STIs may contribute to cervical cancer, infertility, ectopic pregnancy, chronic pelvic pain, and death. Certain infections can be transmitted in utero to the fetus or during childbirth to the newborn (Table 5.1). Additional information on therapeutic management of STIs can be found in Chapter 20.

CULTURAL AND PSYCHOLOGICAL COMPONENTS OF SEXUALLY TRANSMITTED INFECTIONS Nurses should always address a woman’s psychosocial well-being whenever a diagnosis of any STI is given. The woman may be afraid or embarrassed to tell her partner and ask him or her to seek treatment. In some instances, the woman may be afraid that telling her partner may place her in danger of escalating abuse. The nurse can empathize with the woman’s feelings and suggest specific ways of talking with partners that will help decrease her anxiety and assist in efforts to control infection (Reidy et al., 2016). Nurses implementing STI prevention strategies must also acknowledge the possible role of violence in increasing women’s risk as a barrier to practicing safer sex. Research suggests a strong association between intimate partner violence and STIs. Both need to be addressed to reduce the spread of STIs. Even brief interventions in the health care settings are not only feasible but also potentially lifesaving for women experiencing violence in their lives (Durevall & Lindskog, 2015). TABLE 5.1 SEXUALLY TRANSMITTED INFECTIONS AND EFFECTS ON THE FETUS OR NEWBORN

BOX 5.1 CDC CLASSIFICATION OF SEXUALLY TRANSMITTED INFECTIONS • Infections characterized by vaginal discharge • Vulvovaginal candidiasis • Trichomoniasis • Bacterial vaginosis • Infections characterized by cervicitis • Chlamydia • Gonorrhea • Infections characterized by genital ulcers • Genital herpes simplex • Syphilis • Vaccine-preventable STIs • Hepatitis A • Hepatitis B • Human papillomavirus (HPV) • Ectoparasitic infections • Pediculosis pubis • Scabies Adapted from Centers for Disease Control and Prevention [CDC]. (2015k). STD treatment guidelines. Retrieved from http://www.cdc.gov/std/treatment/2010/default.htm.

STIs know no gender, class, racial, ethnic, or social barriers—all individuals are vulnerable if exposed to the infectious organism. The problem of STIs has still not been tackled adequately on a global scale, and until this is done, numbers worldwide will continue to increase. Nurses working with women from diverse cultures need to be cognizant of effective methods of STI prevention (Box 5.2).

Given the high value some cultures place on virginity and fidelity, a diagnosis of an STI can be devastating to the woman and her family. Even to suggest a test for STIs can appear inappropriate or offensive. When a client must be screened for STIs, explaining the need carefully and not revealing to other family members that testing has occurred are essential. By adopting a multicultural approach to the control of STIs, nurses can address specific cultural and religious attitudes and behaviors that influence exposure to STIs (Thomas et al., 2015). To maximize the impact of behavioral interventions and risk reduction programs, the nurse must adjust for social and cultural differences within all diverse populations. Nurses play a crucial role in supporting women from diverse cultures within sexual health services and as trusted health care providers in a range of settings.

BOX 5.2 SEXUALLY TRANSMITTED INFECTIONS IN DIVERSE CULTURES Cultural adaptation is an important step in the process of implementing health promotion interventions that, having been proven to be effective in one culture, are being applied in another. Nurses working with women from diverse cultures need to be cognizant of effective methods of STI prevention. In a recent CDC study, greater prevention intervention efficacy was observed in studies that specifically targeted females of different cultures that used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills. The incidence of STIs was reduced significantly (Thomas et al., 2015). To truly maximize the impact of behavioral interventions and risk reduction programs, nurses must adjust for social and cultural differences within any diverse population group for which they care. Racial minorities continue to face severe disparities in all reportable STIs, but African Americans are the group most affected. Gonorrhea rates among African Americans are higher than those for any other racial or ethnic group and 15 times higher than that of Whites (Kraft et al., 2015). Nurses cannot ignore the glaring racial disparities in rates of STIs. Research has shown that socioeconomic barriers to quality health care and higher overall prevalence of STIs within minority communities contribute to this pervasive threat. It is imperative that the health care team work together to improve access to effective STI prevention and treatment services in local communities for those who need it the most. By adopting a multicultural approach to the control of STIs, nurses can address specific cultural attitudes and behaviors that may impact exposure to STIs and intervene to reduce them.

SEXUALLY TRANSMITTED INFECTIONS AND ADOLESCENTS STIs occur disproportionately in adolescents. An estimated two thirds of all STIs occur among persons under the age of 25. Forty-seven percent of high school students report having been sexually active. These data reinforce existing recommendations for sexual health education and STI prevention targeting adolescents before sexual debut (Liu et al., 2015).

Risk Factors Because of biologic and behavioral factors, adolescents are at particularly high risk for acquiring STIs and for the serious, long-term, potentially life-altering sequelae that can develop from undiagnosed, untreated infections. Each year 5 million cases of STIs occur among teenagers (CDC, 2015a). In the United States, teens who are sexually active experience high rates of STIs, and some groups are at higher risk, including African American youths, abused youths, homeless youths, young men having sex with men, and lesbian, gay, bisexual, and transgendered (LGBT) youths. High-risk factors in adolescents include having multiple or new sexual partners and not using condoms for any number of reasons. Inexperience with condoms also can lead to more condom accidents, such as breakage caused by storage in a hot environment, opening packages with teeth, using long fingernails to put condoms on, slippage if the wrong size condom is used, or failure to hold the condom while withdrawing. Furthermore, some adolescents are unwilling to disclose their sexual activity. If symptoms of an STI develop, they may misperceive them as normal, consequently delaying medical treatment. Untreated STIs can cause pelvic inflammatory disease (PID, which can lead to infertility), adverse pregnancy outcomes, and anogenital and cervical cancers. In addition, the presence of other STIs increases the likelihood of both transmitting and acquiring HIV (Smith, 2015).

Take Note! It is estimated that before graduating from high school, 25% of adolescents will contract an STI (CDC, 2015a). Biologic and behavioral factors place teenagers at high risk. Female adolescents are more susceptible to STIs than males due to their anatomy. During adolescence and young adulthood, women’s columnar epithelial cells are especially sensitive to invasion by sexually transmitted organisms, such as chlamydia and gonococci, because they extend out over the vaginal surface of the cervix, where they are unprotected by cervical mucus; these cells recede to a more protected location as women age. Behaviorally, adolescents and young adults tend to think they are invincible and deny the risks of their behavior. This

risky behavior exposes them to STIs and HIV/AIDS. Adolescents frequently have unprotected intercourse, they engage in partnerships of limited duration, and they face many obstacles that prevent them from using the health care system.

Healthy People 2020 Objective Healthy People 2020 (U.S. Department of Health & Human Services [USDHHS], 2010) provides science-based, 10-year national objectives for improving the health of all people in the United States. For three decades, Healthy People has established benchmarks and monitored progress over time. One specific Healthy People 2020 goal that applies to this chapter is to promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STIs and their complications. An important feature of Healthy People 2020 is its emphasis on responsibility. People need to accept responsibility for their lifestyle choices and behaviors. This personal responsibility is especially important for sexually active adolescents because they contract the highest rate of STIs as a result of making poor choices. Chlamydial and gonorrheal infections are the two most commonly reported bacterial STIs in the United States, and their prevalence is highest among females aged 15 to 24. Human papillomavirus (HPV) infection, trichomoniasis, and herpes simplex virus (HSV) infections are also common in adolescents (Jones, 2015). The Healthy People 2020 objective, “Increase the proportion of sexually active persons aged 15 to 19 years who use condoms to both effectively prevent pregnancy and provide barrier protection against disease,” addresses this personal responsibility focus (USDHHS, 2010). Healthy People 2020’s emphasis on personal responsibility gives adolescents a role in the quality of their lives and the length of healthy life they may have by making the right choices and engaging in nonrisky behaviors.

Nursing Assessment Many health care providers fail to assess adolescent sexual behavior and STI risks, to screen for asymptomatic infection during clinic visits, or to counsel adolescents on STI risk reduction. Nurses need to remember that they play a key role in the detection, prevention, and treatment of STIs in adolescents. All states allow adolescents to give consent to confidential STI testing and treatment. Table 5.2 discusses the clinical manifestations of common STIs in adolescents.

Nursing Management Prevention of STIs among adolescents is critical. Health care providers have a unique opportunity to provide counseling and education to their clients. Adolescents are less willing to be open to nurses and less likely to return for care if they are uncertain about confidentiality. Nurses working with adolescents need to convey their willingness to discuss sexual habits, and any interactions with clients need to be direct and nonjudgmental. Nurses can provide effective guidance and promote sexual health so that primary or repeat infections can be avoided. Adolescents bear disproportionate burdens when it comes to STIs, so education is needed to help them protect their reproductive futures. Specific actions to take include the following: • Encourage the client to complete antibiotic prescriptions (specific management for each type of STI is discussed below). • Adapt the style and content of any message to the client’s developmental level. • Identify risk factors and risk behaviors and guide the client to develop specific individualized actions of prevention. • Teach adolescents about their sexual development to foster understanding of their bodily changes—the role of hormones and the emotions they are experiencing. • Encourage adolescents to postpone initiation of sexual intercourse for as long as possible, but if they choose to have sexual intercourse, explain the necessity of using barrier methods, such as male and female condoms (Teaching Guidelines 5.1). For teens who have already had sexual intercourse, the clinician can encourage abstinence at this point. If adolescents are sexually active, they should be directed to teen clinics, and contraceptive options should be explained. In areas where specialized teen clinics are not available, nurses should feel comfortable discussing sexuality, safety, and contraception with teens. Encourage adolescents to minimize their lifetime number of sexual partners, to use barrier methods consistently and correctly, and to be aware of the connection between drug and alcohol use and the incorrect use of barrier methods. Table 5.3 discusses barriers to condom use and means to overcome them. TABLE 5.2 COMMON SEXUALLY TRANSMITTED INFECTIONS

HEALTHY PEOPLE 2020 • 5.1

HEALTHY PEOPLE 2020 • 5.2

TABLE 5.3 CANADIAN GUIDELINES: BARRIERS TO CONDOM USE AND MEANS TO OVERCOME THEM

Teaching Guidelines 5.1

PROPER CONDOM USE • Use latex condoms to create a mechanical barrier for STIs and pregnancy • Use a new condom with each act of sexual intercourse. Never reuse a condom. • Handle condoms with care to prevent damage from sharp objects such as fingernails and teeth. • Ensure condom has been stored in a cool, dry place away from direct sunlight. Do not store condoms in wallet or automobile or anywhere they would be exposed to extreme temperatures. • Do not use a condom if it appears brittle, sticky, or discolored. These are signs of aging. • Put condom on before any genital contact because sperm is present in

preejactulate fluid. • Put condom on when penis is erect. Ensure it is placed so it will readily unroll. • Hold the tip of the condom while unrolling. Ensure there is a space at the tip for semen to collect, but make sure no air is trapped in the tip. • Ensure adequate lubrication during intercourse. If external lubricants are used, use only water-based lubricants such as K-Y jelly with latex condoms. Oil-based or petroleum-based lubricants, such as body lotion, massage oil, or cooking oil, can weaken latex condoms. • Withdraw while penis is still erect, and hold condom firmly against base of penis. Adapted from Kimberlin, D. W. (Ed.). (2015). Red Book Online: Report of the committee on infectious diseases (30th ed.). Retrieved from http://redbook.solutions.aap.org/; and Public Health Agency of Canada. (2015). Canadian guidelines on sexually transmitted infections. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/pdf/401mts-prisencharge-eng.pdf.

Think back to Sandy, who was introduced at the beginning of the chapter. How should the nurse handle Sandy’s anxious state? What specific questions should the nurse ask Sandy to determine the source of the possible infection in her genital area?

INFECTIONS CHARACTERIZED BY VAGINAL DISCHARGE Vaginitis is a generic term that means inflammation and infection of the vagina. Vaginitis has hundreds of causes, but more often than not the cause is infection by one of three organisms: • Candida, a fungus • Trichomonas, a protozoan • Gardnerella, a bacterium The complex balance of microbiologic organisms in the vagina is a key element in the maintenance of health. Subtle shifts in the vaginal environment may allow organisms with pathologic potential to proliferate, causing infectious symptoms. The nurse’s role in managing vaginitis is one of primary prevention and education to limit recurrences of these infections. Primary prevention begins with changing the sexual behaviors that place women at risk for infection. In addition to assessing women for the common signs and symptoms and risk factors, the nurse can help women to avoid vaginitis or to prevent a recurrence by teaching them to take the precautions highlighted in Teaching Guidelines 5.2.

Teaching Guidelines 5.2

PREVENTING VAGINITIS • Avoid douching to prevent altering the vaginal environment. • Use condoms to avoid spreading the organism. • Avoid tights, nylon underpants, and tight clothes. • Wipe from front to back after using the toilet. • Wash only with hypoallergenic bar soaps; avoid using liquid soaps or body washes.

• Avoid powders, bubble baths, and perfumed vaginal sprays. • Wear clean cotton underpants. • Change out of wet bathing suits as soon as possible. • Become familiar with the signs and symptoms of vaginitis. • Choose to lead a healthy lifestyle.

Genital/Vulvovaginal Candidiasis Genital/vulvovaginal candidiasis (VVC) is one of the most common causes of vaginal discharge. It is also referred to as yeast, monilia, and a fungal infection. It is not considered an STI because Candida is a normal constituent in the vagina and becomes pathologic only when the vaginal environment becomes altered. An estimated 75% of women will have at least one episode of VVC, and 40% to 50% will have two or more episodes in their lifetime (CDC, 2015b).

Therapeutic Management Treatment of candidiasis includes one of the following medications: • Miconazole (Monistat) cream or suppository • Clotrimazole (Mycelex) tablet or cream • Terconazole (Terazol) cream or intravaginal suppository • Fluconazole (Diflucan) oral tablet (Prabhu & Gardella, 2015). Most of the above medications are used intravaginally in the form of a cream, tablet, or suppositories for 3 to 7 days. If fluconazole (Diflucan) is prescribed, a 150-mg oral tablet is taken as a single dose. Topical azole preparations are effective in the treatment of VVC, relieving symptoms and producing negative cultures in 80% to 90% of women who complete therapy (CDC, 2015b). If VVC is not treated effectively during pregnancy, the newborn can develop an oral infection known as thrush during the birth process; that infection must be treated with a local azole preparation after birth.

Nursing Assessment Assess the client’s health history for predisposing factors for VVC, which include: • Pregnancy • Use of oral contraceptives with high estrogen content • Use of broad-spectrum antibiotics • Diabetes mellitus

• Obesity • Use of steroid and immunosuppressive drugs • HIV infection • Wearing tight, restrictive clothes and nylon underpants • Trauma to vaginal mucosa from chemical irritants or douching Assess the client for clinical manifestations of genital/vulvovaginal candidiasis. Typical symptoms, which can worsen just before menses, include: • Pruritus • Vaginal discharge (thick, white, curd-like) • Vaginal soreness • Vulvar burning • Erythema in the vulvovaginal area • Dyspareunia • External dysuria Figure 5.1 shows the typical appearance of VVC. Speculum examination will reveal white plaques on the vaginal walls. The vaginal pH remains within normal range. Definitive diagnosis is made by a wet smear, which reveals the filamentous hyphae and spores characteristic of a fungus when viewed under a microscope.

FIGURE 5.1 Vulvovaginal candidiasis. (Asset provided by Anatomical Chart Co.)

Nursing Management Teach the following preventive measures to women with frequent VVC infections: • Reduce dietary intake of simple sugars and soda. • Wear white, 100% cotton underpants. • Avoid wearing tight pants or exercise clothes with spandex. • Shower rather than taking tub baths. • Wash with a mild, unscented soap and dry the genitals gently. • Avoid the use of bubble baths or scented bath products. • Wash underwear in unscented laundry detergent and hot water. • Dry underwear in a hot dryer to kill the yeast that clings to the fabric. • Remove wet bathing suits promptly. • Practice good body hygiene.

• Avoid vaginal sprays/deodorants. • Avoid wearing pantyhose (or cut out the crotch to allow air circulation). • Use white, unscented toilet paper and wipe from front to back. • Avoid douching (which washes away protective vaginal mucus). • Avoid the use of superabsorbent tampons (use pads instead).

Trichomoniasis Trichomoniasis is another common vaginal infection that causes a discharge, but is not always sexually transmitted. The organism can live on damp/wet surfaces and poorly cleaned/maintained hot tubs and drains. The woman may be markedly symptomatic or asymptomatic. Men are asymptomatic carriers. Although this infection is localized, there is increasing evidence of preterm birth, premature rupture of membranes, low-birth-weight infants, postpartum endometritis, and infertility in women with this vaginitis. The high prevalence of this infection worldwide and frequency of co-infection with other STIs make trichomoniasis a compelling public health concern. Notably, research has shown that infection with trichomoniasis increases the risk of HIV transmission in both men and women (Smith & Ramos, 2015). Trichomonas vaginalis is an ovoid, single-cell protozoan parasite that can be observed under the microscope making a jerky swaying motion. In the United States, an estimated 3.7 million people have the infection, but only about 30% develop any symptoms of trichomoniasis. Infection is more common in women than in men, and older women are more likely than younger women to have been infected (CDC, 2015c).

Therapeutic Management A single 2-g dose of oral metronidazole (Flagyl) or tinidazole (Tindamax) for both partners is a common treatment for this infection. Sex partners of women with trichomoniasis should be treated to avoid recurrence of infection.

Nursing Assessment Assess the client for clinical manifestations of trichomoniasis, which include: • A heavy yellow/green or gray frothy or bubbly discharge • Vaginal pruritus and vulvar soreness • Dyspareunia • A cervix that may bleed on contact • Dysuria • Vaginal odor, described as foul • Vaginal or vulvar erythema

• Petechiae on the cervix Figure 5.2 shows the typical appearance of trichomoniasis. The diagnosis is confirmed when a motile flagellated trichomonad is visualized under the microscope. In addition, a vaginal pH of greater than 4.5 is a typical finding. U.S. Food and Drug Administration (FDA)-approved tests for trichomoniasis in women include the OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, MA), an immunochromatographic capillary flow dipstick technology, and the Affirm VPIII (Becton Dickinson, San Jose, CA), a nucleic acid probe test that evaluates for T. vaginalis, Gardnerella vaginalis, and Candida albicans. Each of these tests, which are performed on vaginal secretions, has a sensitivity of >83% and a specificity of >97%. Both tests are considered point-of-care diagnostics (CDC, 2015c).

Nursing Management Instruct clients to avoid sex until they and their sex partners are cured (i.e., when therapy has been completed and both partners are symptom-free) and also to avoid consuming alcohol during treatment because mixing the medications and alcohol causes severe nausea and vomiting (CDC, 2015c). In addition, it is important to provide information regarding infection cause and transmission, effects on reproductive organs and future fertility, and the need for partner notification and treatment. Follow-up testing is not indicated if symptoms resolve with treatment. See Evidence-Based Practice 5.1 for interventions for trichomoniasis in pregnancy.

Bacterial Vaginosis A third common infection of the vagina is bacterial vaginosis (BV) caused by the gram-negative bacillus G. vaginalis. It is the most prevalent cause of vaginal discharge or malodor, but up to 50% of women are asymptomatic. BV is a sexually associated infection characterized by alterations in vaginal flora in which lactobacilli in the vagina are replaced with high concentrations of anaerobic bacteria. BV was named so because bacteria are the etiologic agents and an associated inflammatory response is lacking. The bacterial imbalance is associated with sexual contact, but is not usually spread through sex. The cause of the microbial alteration is not fully understood but is associated with having multiple sex partners, douching, and lack of vaginal lactobacilli (CDC, 2015d). Research suggests that BV is associated with preterm labor, premature rupture of membranes, chorioamnionitis, postpartum endometritis, and PID (CDC, 2015d).

FIGURE 5.2 Trichomoniasis. (Asset provided by Anatomical Chart Co.)

EVIDENCE-BASED PRACTICE 5.1 ADOLESCENT PATIENT PREFERENCES SURROUNDING PARTNER NOTIFICATION FOR SEXUALLY TRANSMITTED INFECTIONS

STUDY A sexually transmitted epidemic exists among adolescents. Important barriers to addressing the sexually transmitted infection (STI) epidemic among adolescents are the inadequate partner notification of positive STI results and insufficient rates of partner testing and treatment. However, adolescent attitudes regarding partner notification and treatment are not well understood. The objective of this study was to qualitatively explore the barriers to and preferences for partner notification and treatment among adolescent males and females tested for STIs in an emergency department (ED) setting and to explore the acceptability of ED personnel notifying their sexual partners. This was a descriptive, qualitative study in which a convenience sample of 40 adolescents (18 females, 22 males) 14 to 21 years of age who presented to either adult or pediatric EDs with STI-related complaints participated. Data were analyzed using framework analysis.

Findings Barriers to partner notification included fear of retaliation or loss of the relationship, lack of understanding of or concern for the consequences associated with an STI, and social stigma and embarrassment. Participants reported two primary barriers to their partners obtaining STI testing and treatment: lack of transportation to the health care site and the partner’s fear of STI-positive test results. Most participants were agreeable with a health care provider notifying their sexual partners of the STI exposure by phone.

Nursing Implications Since several barriers exist to addressing the STI epidemic among adolescents, nurses can intervene by assisting partner notification and treatment to reduce spread. Adolescents may lack the communication skills and developmental maturity to address a difficult topic such as STIs with their partners. Partner notification of STI exposures is essential to reduce the rates of STIs among adolescents. Nurses can help in this endeavor by participating in the STI notification process to prevent further spread and reduction of future complications. Adapted from Reed, J. L., Huppert, J. S., Gillespie, G. L., Taylor, R. G., Holland, C. K., Alessandrini, E. A., et al. (2015). Adolescent patient preferences surrounding partner notification and treatment for sexually transmitted infections. Academic Emergency Medicine, 22(1), 61–66.

Therapeutic Management Treatment for BV includes oral metronidazole (Flagyl) or clindamycin (Cleocin) cream. Treatment of the male partner has not been beneficial in preventing recurrence because sexual transmission of BV has not been proven (CDC, 2015d).

Nursing Assessment Assess the client for clinical manifestations of BV. Primary symptoms are a thin, white homogeneous vaginal discharge and a characteristic “stale fish” odor, often recognized only after sexual intercourse. Figure 5.3 shows the typical appearance of BV. To diagnose BV, three of the following four criteria must be met: • Thin, grayish white homogeneous vaginal discharge which adheres to the vaginal mucosa • Vaginal pH > 4.5 • Positive “whiff test” (secretion is mixed with a drop of 10% potassium hydroxide on a slide, producing a characteristic stale fishy odor) • A pH greater than 4.5

• The presence of clue cells on wet-mount examination (CDC, 2015d).

Nursing Management The nurse’s role is one of primary prevention and education to limit recurrences of these infections. Primary prevention begins with changing hygiene behaviors that place women at risk for infection. In addition to assessing women for common signs, symptoms, and risk factors (recent antibiotic use, decreased estrogen production, douching, and sexual activity with a new partner), the nurse can help women to avoid vaginitis or to prevent a recurrence by teaching them to take the precautions highlighted in Teaching Guidelines 5.2.

FIGURE 5.3 Bacterial vaginosis. (Illustration provided by Anatomical Chart Co. Photograph from Sweet, R. L., & Gibbs, R. S. [2005]. Atlas of infectious diseases of the female genital tract. Philadelphia, PA: Lippincott Williams & Wilkins.)

INFECTIONS CHARACTERIZED BY CERVICITIS Cervicitis is a catchall term that implies the presence of inflammation or infection of the cervix. It is used to describe everything from symptomless erosions to an inflamed cervix that bleeds on contact and produces quantities of purulent discharge containing organisms not ordinarily found in the vagina. Cervicitis is usually caused by gonorrhea or chlamydia, as well as almost any pathogenic bacterial agent and a number of viruses. The treatment of cervicitis involves the appropriate therapy for the specific organism that has caused it.

Chlamydia Chlamydia is the most commonly reported bacterial STI in the United States. The CDC (2015e) estimates that over 3 million new cases occur each year; the highest predictor for the infection is age. The highest rates of infection are among those aged 15 to 19, mainly because their sexual relations are often unplanned and are sometimes the result of rape, and typically happen before they have the experience and skills to protect themselves. The rates are highest among this group regardless of demographics or location (CDC, 2015e). The young have the most to lose from acquiring STIs, because they will suffer the consequences the longest and might not reach their full reproductive potential. The most common risk factors associated with chlamydia are age >25 years, recent change in sexual partner or multiple sexual partners, poor socioeconomic conditions, exchange of sex for money, non-White race, single status, and lack of use of barrier contraception (Qureshi, 2015). Asymptomatic infection is common among both men (50%) and women (70%). Men primarily develop urethritis. In women, chlamydia is linked with cervicitis, acute urethral syndrome, salpingitis, chronic pelvic pain, dysuria, stillbirth, ectopic pregnancy, PID, and infertility (Simmons, 2015). Chlamydia causes half of the 1 million recognized cases of PID in the United States each year, and treatment costs run over $800 million yearly. The CDC recommends yearly chlamydia testing of all sexually active women aged 25 or younger, older women with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners), and all pregnant women (CDC, 2015e). Chlamydia trachomatis is the bacterium that causes chlamydia. It is an intracellular parasite that cannot produce its own energy and depends on the host for survival. It is often difficult to detect, and this can pose problems for women due to the long-term consequences of untreated infection. Untreated chlamydia has been linked to increased incidence and severity of sequelae, such as PID and infertility in women. After a single chlamydial infection, the risk of developing PID is estimated to be approximately 20% to 50% %, and the risk of developing tubal infertility is estimated to be approximately 10% to 20% (Amoako & Balen, 2015). Moreover, lack of treatment provides more opportunity for the infection to be transmitted to sexual partners. An estimated 100,000 pregnant women are affected by this STI. When untreated, chlamydia is associated with premature rupture of membranes, preterm labor, and postpartum endometritis (Collins,

2015). Newborns delivered to infected mothers may develop conjunctivitis, which occurs in 1% to 12% of all newborns. Ophthalmia neonatorum is an acute mucopurulent conjunctivitis occurring in the first month of birth. It is essentially an infection acquired during vaginal delivery. The most frequent infectious agents involved in are C. trachomatis and Neisseria gonorrhoeae (Moore & MacDonald, 2015).

Therapeutic Management Antibiotics are usually used in treating this STI. The CDC treatment options for chlamydia include doxycycline (Vibramycin) 100 mg orally twice a day for 7 days or azithromycin (Zithromax) 1 g orally in a single dose. Because of the common co-infection of chlamydia and gonorrhea, a combination regimen of ceftriaxone (Rocephin) with doxycycline or azithromycin is prescribed frequently (CDC, 2015e). Additional CDC guidelines for client management include annual screening of all sexually active women aged 20 to 25 years, screening of all high-risk people, and treatment with antibiotics effective against both gonorrhea and chlamydia for anyone diagnosed with a gonococcal infection (CDC, 2015e). Except in pregnant women, test-of-cure (repeat testing 3 to 4 weeks after completing therapy) is not recommended for women treated with the recommended or alterative regimens, unless therapeutic adherence is in question, symptoms persist, or reinfection is suspected. Pregnant women should be retested in 3 to 6 months after the initial infection, preferably in the third trimester, because of an increased risk for reinfection (King et al., 2015).

Nursing Assessment Assess the health history for significant risk factors for chlamydia, which may include: • Being an adolescent • Having multiple sex partners • Having a new sex partner • Engaging in sex without using a barrier contraceptive (condom) • Using oral contraceptives • Being pregnant

• Having a history of another STI (Schuiling & Likis, 2016). Assess the client for clinical manifestations of chlamydia. The majority of women (70%) are asymptomatic (CDC, 2015e). If the client is symptomatic, clinical manifestations include: • Mucopurulent vaginal discharge • Urethritis • Bartholinitis • Endometritis • Salpingitis • Dysfunctional uterine bleeding The diagnosis can be made by urine testing or swab specimens collected from the endocervix or vagina. Culture, direct immunofluorescence, enzyme immunoassay, or nucleic acid amplification methods by polymerase chain reaction or ligase chain reaction (DNA probe, such as GenProbe or Pace2) are highly sensitive and specific when used on urethral and cervicovaginal swabs. They can also be used with good sensitivity and specificity on first-void urine specimens (King et al., 2015). The chain reaction tests are the most sensitive and cost-effective. Because the majority of chlamydia cases are asymptomatic, the CDC recommends screening of all women with a new sex partner and annual screening for women 25 years and younger (CDC, 2015e). Chlamydia is an important preventable cause of infertility and other adverse reproductive health outcomes. Effective prevention interventions are available to reduce the burden of chlamydia and its sequelae, but they are underutilized. Although many prevention programs are available, improvements can be made in raising awareness about chlamydia, increasing screening coverage, and enhancing partner services. In addition, nurses can focus their efforts on reaching disproportionately affected racial/ethnic groups. To break the cycle of chlamydia transmission in the United States, health care providers should encourage annual chlamydia screening for all sexually active females less than 25 years old, maximize use of effective partner treatment services, and rescreen infected females and males 3 months after treatment (CDC, 2015e).

Gonorrhea Gonorrhea is a serious and potentially very severe bacterial infection. It is the second most commonly reported infection in the United States and globally is an urgent problem because it is now capable of rapidly developing resistance to multiple antibiotic classes. Gonorrhea is highly contagious and is a reportable infection to the health department authorities. Gonorrhea increases the risk for PID, infertility, ectopic pregnancy, and HIV acquisition and transmission (CDC, 2015f). It is rapidly becoming more and more resistant to cure. In the United States, over 820,000 new gonorrhea infections occur annually, with 570,000 of them occurring among young people 15 to 24 years old (CDC, 2015f). In common with all other STIs, it is an equal-opportunity infection—no one is immune to it, regardless of race, creed, gender, age, or sexual preference. The cause of gonorrhea is an aerobic gram-negative intracellular diplococcus, N. gonorrhoeae. The site of infection is the columnar epithelium of the endocervix. Gonorrhea is almost exclusively transmitted by sexual activity. In pregnant women, gonorrhea is associated with chorioamnionitis, premature labor, premature rupture of membranes, and postpartum endometritis (Piszczek, Jean, & Khaliq, 2015). It can also be transmitted to the newborn in the form of ophthalmia neonatorum during birth by direct contact with gonococcal organisms in the cervix. Ophthalmia neonatorum is highly contagious and, if untreated, leads to blindness in the newborn.

Therapeutic Management Gonorrhea can be cured with the right treatment. CDC now recommends dual therapy (i.e., using two drugs) as the treatment for gonorrhea. Dual drug therapy is recommended to prevent drug resistance, and is also effective against chlamydia. The treatment of choice for uncomplicated gonococcal infections is a single intramuscular dose of ceftriaxone (Rocephin) 250 mg plus a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice a day for 7 days (Kohlhoff & Hammerschlag, 2015; Wong, 2015). Pregnant women should not be treated with quinolones or tetracyclines. Pregnant women with a positive test for gonorrhea should be treated with the same recommended dual therapy as above (CDC, 2015f). To prevent gonococcal ophthalmia neonatorum, a prophylactic agent should be instilled into the eyes of all newborns; this procedure is required

by law in most states. Erythromycin or tetracycline ophthalmic ointment in a single application is recommended (CDC, 2015f). With use of recommended treatment, follow-up testing to document eradication of gonorrhea is no longer recommended. Instead, rescreening in 3 months to identify reinfection is suggested (CDC, 2015f).

Nursing Assessment Assess the client’s health history for risk factors, which may include low socioeconomic status, living in an urban area, single status, inconsistent use of barrier contraceptives, age under 25 years old, and multiple sex partners. Assess the client for clinical manifestations of gonorrhea, keeping in mind that 70% of women infected with gonorrhea are totally symptom-free (Wong, 2015). Because women are so frequently asymptomatic, they are regarded as a major factor in the spread of gonorrhea. If symptoms are present, they might include: • Abnormal vaginal discharge • Dysuria • Cervicitis • Abnormal vaginal bleeding • Bartholin’s abscess • Enlarged lymph nodes locally • PID • Neonatal conjunctivitis in newborns • Mild sore throat (for pharyngeal gonorrhea) • Rectal infection (itching, soreness, bleeding, discharge) • Perihepatitis (King et al., 2015). Sometimes a local gonorrheal infection is self-limiting (there is no further spread), but usually the organism ascends upward through the endocervical canal to the endometrium of the uterus, further on to the fallopian tubes, and out into the peritoneal cavity. When the peritoneum and the ovaries become involved, the condition is known as PID (discussed later in this chapter). The scarring to the fallopian tubes is permanent. This damage is a major cause of infertility and is a possible contributing factor in ectopic pregnancy (Heller, 2015).

FIGURE 5.4 Gonorrhea. (From Gorbach, S. L., et al. [2004]. Infectious diseases. Philadelphia, PA: Lippincott Williams & Wilkins.)

If gonorrhea remains untreated, it can enter the bloodstream and produce a disseminated gonococcal infection. This severe form of infection can invade the joints (arthritis), the heart (endocarditis), the brain (meningitis), and the liver (toxic hepatitis). Figure 5.4 shows the typical appearance of gonorrhea. The CDC recommends screening for all women at risk for gonorrhea. Pregnant women should be screened at the first prenatal visit and again at 36 weeks of gestation. Nucleic acid hybridization tests (GenProbe) are used for diagnosis. Any woman suspected of having gonorrhea should be tested for chlamydia also because co-infection (45%) is extremely common (CDC, 2015f).

Nursing Management of Chlamydia and Gonorrhea The prevalence of chlamydia and gonorrhea is increasing dramatically, and these infections can have long-term effects on people’s lives. Sexual health is an important part of a person’s physical and mental health, and nurses have a professional obligation to address it. Be particularly sensitive when addressing STIs because women are often embarrassed, feel guilty or angry, or may even be fearful of outcomes related to telling partners about the diagnosis (see earlier

section on the cultural and psychological impacts of STI diagnosis). There is still a social stigma attached to STIs, so women need to be reassured about confidentiality. The nurse’s knowledge about chlamydia and gonorrhea should include treatment strategies, referral sources, and preventive measures. The nurse should be skilled at client education and counseling and be comfortable talking with, and advising, women diagnosed with these infections. Provide education about risk factors for these infections. High-risk groups include single women, women younger than 25 years old, African American women, women with a history of STIs, those with new or multiple sex partners, those with inconsistent use of barrier contraception, and women living in communities with high infection rates (Comkornruecha, 2013). Assessment involves taking a health history that includes a comprehensive sexual history. Ask about the number of sex partners and the use of safer sex techniques. Review previous and current symptoms. Emphasize the importance of seeking treatment and informing sex partners. The four-level P-LI-SS-IT model (Box 5.3) can be used to determine interventions for various women because it can be adapted to the nurse’s level of knowledge, skill, and experience. Of utmost importance is the willingness to listen and show interest and respect in a nonjudgmental manner. In addition to meeting the health needs of women with chlamydia and gonorrhea, the nurse is responsible for educating the public about the increasing incidence of these infections. This information should include high-risk behaviors associated with these infections, signs and symptoms, and the treatment modalities available. Stress that both of these STIs can lead to infertility and long-term sequelae. Teach safer sex practices to people in nonmonogamous relationships. Know the physical and psychosocial responses to these STIs to prevent transmission and the disabling consequences. Nurses must also inform their pregnant clients that they should avoid quinolones or tetracyclines to prevent risks associated with irreversible tooth discoloration and enamel hypoplasia in the newborn (Kohlhoff & Hammerschlag, 2015).

BOX 5.3 THE P-LI-SS-IT MODEL P Permission—gives the woman permission to talk about her experience LI Limited Information—information given to the woman about STIs • Factual information to dispel myths about STIs • Specific measures to prevent transmission • Ways to reveal information to her partners • Physical consequences if the infections are untreated SS Specific Suggestions—an attempt to help women change their behavior to prevent recurrence and prevent further transmission of the STI IT Intensive Therapy—involves referring the woman or couple for appropriate treatment elsewhere based on their life circumstances Adapted from Annon, J. S. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral treatment of sexual problems. Journal of Sex Education Therapy, 2, 1–15.

Take Note! If the epidemic of chlamydia and gonorrhea is to be halted, nurses must take a major front-line role now.

INFECTIONS CHARACTERIZED BY GENITAL ULCERS In the United States, the majority of young, sexually active clients who have genital ulcers have genital herpes, syphilis, or chancroid. The frequency of each condition differs by geographic area and client population; however, genital herpes is the most prevalent of these diseases (CDC, 2015g). More than one of these diseases can be present in a client who has genital ulcers. All three of these diseases have been associated with an increased risk for HIV infection. Not all genital ulcers are caused by STIs.

Genital Herpes Simplex Genital herpes is a recurrent, lifelong viral infection that has the potential for transmission throughout the lifespan. The CDC (2015h) estimates that one out of six people in the United States have genital HSV infection, with 776,000 people getting new cases annually. About 22% of pregnant women are infected with HSV. The most devastating consequence of maternal genital herpes is neonatal herpes disease, which occurs in approximately 1 in 3,200 births in the US and has a high mortality rate (James & Kimberlin, 2015). Genital herpes is more common among females (1 out of 5) than males (1 out of 9) in part due to prolonged contact with semen during vaginal intercourse. Two serotypes of HSV have been identified: HSV-1 and HSV-2. HSV-1 is associated mainly with oral herpes (commonly called cold sores and fever blisters) and HSV-2 is mainly associated with genital herpes, both types can cause outbreaks in either location. Approximately 80% of individuals infected with genital herpes are asymptomatic and unaware of being infected with the virus (Leone, 2015). HSV is transmitted by contact of mucous membranes or breaks in the skin with visible or nonvisible lesions. Most genital herpes infections are transmitted by individuals unaware that they have an infection. Many have mild or unrecognized infections but still shed the herpes virus intermittently. HSV is transmitted primarily by direct contact with an infected individual who is shedding the virus. Kissing, sexual contact (including oral sex), and vaginal delivery are means of transmission. Having sex with an infected partner places the individual at risk for contracting HSV. After the primary outbreak, the virus remains dormant in the nerve cells for a lifetime, resulting in periodic recurrent outbreaks. Recurrent genital herpes outbreaks are triggered by precipitating factors such as emotional stress, menses, ultraviolet light exposure, illness, surgery, fatigue, genital trauma, immunosuppression, and sexual intercourse, but more than half of recurrences occur without a precipitating cause. Immunocompromised women have more frequent and more severe recurrent outbreaks than normal hosts. A genital herpes infection during pregnancy can cause a spontaneous abortion, preterm labor, microcephaly, low-birth-weight infant, microophthalmia, chorioretinitis, and/or neonatal HSV infection (Silasi et al., 2015). Living with genital herpes can be difficult due to the erratic, recurrent nature

of the infection, the location of the lesions, the unknown causes of the recurrences, and the lack of a cure. Upon diagnosis, clients have important concerns related not to the physical nature of the disease but to the social consequences, including transmission and the impact on their sex life. Furthermore, the stigma associated with this infection may affect the individual’s feelings about herself and her interaction with partners. Potential psychosocial consequences may include emotional distress, isolation, fear of rejection by a partner, fear of transmission of the disease, loss of confidence, and altered interpersonal relationships (Alexander et al., 2014). Along with the increase in the incidence of genital herpes has been an increase in neonatal HSV infections, which are associated with a high incidence of mortality and morbidity. The risk of neonatal infection with a primary maternal outbreak is between 30% and 50%; it is less than 1% with a recurrent maternal infection (CDC, 2015h).

Therapeutic Management No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes. Advances in treatment with acyclovir (Zovirax) 400 mg orally three times daily for 7 to 10 days, famciclovir (Famvir) 250 mg orally three times daily for 7 to 10 days, or valacyclovir (Valtrex) 1 g orally twice daily for 7 to 10 days have resulted in an improved quality of life for those infected with HSV. However, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued (CDC, 2015h). Suppressive therapy is recommended for individuals with six or more recurrences per year. The natural course of the disease is for recurrences to be less frequent over time. The safety of antiviral therapy has not been established during pregnancy. Therapeutic management also includes counseling regarding the natural history of the disease, the risk of sexual and perinatal transmission, and the use of methods to prevent further spread. The following guidelines can help the nurse when delivering information in a time-limited environment: (1) Use all available client reading materials; (2) have another knowledgeable staff member in the office who can spend extra time with women who need it; (3) refer clients to good and accurate websites such as the American Social Health Association website (refer to for additional information); (4) know the phone numbers of herpes support groups in your area; (5) educate the client to abstain from all

sexual activity until HSV lesions resolve; (6) use good hand hygiene to prevent spread; (7) educate that there is no cure, and that practicing safer sex (using condoms and dental dams) with every sex act is essential to prevent transmission; and (8) encourage all clients to inform their current sex partners that they have genital herpes and to inform future partners before initiating a sexual relationship. Finally, many experts recommend a sympathetic, nonjudgmental approach. The nurse can state in clear terms that having herpes does not change the core of the person or make the person less worthwhile (Myers et al., 2015).

Nursing Assessment Assess the woman for risk factors, which may include having unprotected sexual intercourse, multiple sexual partners, lower socioeconomic status, a history of STIs, and increasing age (Moses, 2015). Assess the client for clinical manifestations of HSV. Clinical manifestations can be divided into the primary episode and recurrent infections. The first or primary episode is usually the most severe, with a prolonged period of viral shedding. Primary HSV is a systemic disease characterized by multiple painful vesicular lesions, mucopurulent discharge, superinfection with candida, fever, chills, malaise, dysuria, headache, genital irritation, inguinal tenderness, and lymphadenopathy. The lesions in the primary herpes episode are frequently located on the vulva, vagina, and perineal areas. The vesicles will open and weep and finally crust over, dry, and disappear without scar formation (Fig. 5.5). This viral shedding process usually takes up to 2 weeks to complete. Recurrent infection episodes may occur five to eight times per year and are usually much milder with fewer lesions and shorter in duration than the primary one. Tingling, itching, pain, unilateral genital lesions, and a more rapid resolution of lesions are characteristics of recurrent infections. Recurrent herpes is a localized disease characterized by typical HSV lesions at the site of initial viral entry. Recurrent herpes lesions are fewer in number and less painful and resolve more rapidly (King et al., 2015).

FIGURE 5.5 Genital herpes simplex. (Illustration provided by Anatomical Chart Co. Photograph courtesy of Stephen Ludwig, MD.)

Diagnosis of HSV is often based on clinical signs and symptoms and is confirmed by viral culture of fluid from the vesicles. The IgG/IgM antibody testing is frequently done for screening purposes. Papanicolaou (Pap) smears are an insensitive and nonspecific diagnostic test for HSV and should not be relied on for diagnosis. The women should be tested for all common STIs, especially if she has a new sexual partner. Ideally, the woman will initiate an open conversation with her sexual partner about the risk of transmission and the need for safer sexual practices.

Syphilis Syphilis is a complex, curable bacterial infection caused by the spirochete Treponema pallidum. It is often thought to be a disease of the past, largely eradicated in modern America, but its incidence is on the rise in certain populations (gay men, bisexual men, men having sex with men, and women of color living in the South). It is estimated that 12 million people globally are infected annually (Ramsey, 2015). It is a serious systemic disease that can lead to disability and death if untreated. Syphilis has a complex life cycle during which episodes of active clinical disease are punctuated with periods of latency. About 2.1 million pregnant women have active syphilis every year. Congenital syphilis can occur when an infected mother directly infects her fetus. Without screening and treatment, 69% of these women will have an adverse outcome to their pregnancy (Angoori, 2015). Rates of syphilis in the United States are increasing, especially among young adults and African Americans in urban areas and in the South (CDC, 2015i). The World Health Organization (WHO, 2015d) estimates that the rates of maternal syphilis and subsequent neonatal mortality and morbidity easily exceed that of other neonatal infections, especially among lower socioeconomic classes, aboriginal and African American cultures, and sex trade workers. It continues to be one of the most important STIs both because of its biologic effect on HIV acquisition and transmission and because of its impact on infant health (Tipple & Taylor, 2015). All pregnant women should be screened for syphilis infection at their first prenatal visit and repeated in the third trimester For women in high-risk groups, repeat serology testing may be necessary in the third trimester and at birth (CDC, 2015j). The syphilis spirochete rapidly penetrates intact mucous membranes or microscopic lesions in the skin and within hours enters the lymphatic system and bloodstream to produce a systemic infection long before the appearance of a primary lesion. The site of entry may be vaginal, rectal, or oral (Klein, McLaud, & Rogers, 2015). The syphilis spirochete can cross the placenta after 9 weeks of gestation. One out of every 10,000 infants born in the United States has congenital syphilis (CDC, 2015i). Maternal infection consequences for the newborn include spontaneous abortion, low birth weight, prematurity, stillbirth, intrauterine growth restriction, and multisystem failure of the heart, lungs, spleen, liver, and pancreas, as well as structural bone damage, nervous system involvement, and intellectual disability (Chen et al., 2015).

Therapeutic Management Fortunately, an effective treatment is available for syphilis. Single-dose therapy is preferred for ease of use of azithromycin (Zithromax, Z-Pak) 1 g orally once, or ceftriaxone (Rocephin) 250 mg IM once or ciprofloxacin (Cipro) 500 mg orally twice a day for three days, or erythromycin base 500 mg orally three times a day for seven days can be prescribed. Ciprofloxacin is contraindicated for pregnant and lactating women. Penicillin G benzathine 2.4 million units IM weekly for 3 weeks can also be used for treatment, but client adherence can be challenging (King et al., 2015). The preparations used, the dosage, and the length of treatment depend on the stage and clinical manifestations of disease (CDC, 2015j). Other medications, such as doxycycline, are available if the client is allergic to penicillin. Women should be reevaluated at 6 and 12 months after treatment for primary or secondary syphilis with additional serologic testing. Women with latent syphilis should be followed clinically and serologically at 6, 12, and 24 months (Lawrence et al., 2015). Concept Mastery Alert Syphilis Transmission in Pregnancy Although some sexually transmitted infections such as gonorrhea and the herpes virus are transmitted to the newborn by the birth canal, syphilis is transmitted through the placenta at any time during the pregnancy. This means the fetus is at risk during the entire pregnancy, unless the mother is diagnosed and properly treated.

Nursing Assessment Syphilis has many nonspecific signs and symptoms that may be overlooked by the health care provider, or may simply be indistinguishable from other more common diseases. Regrettably, undiagnosed and untreated syphilis may lead to life-threatening complications such as hepatitis, stroke, and nervous system damage (Klein et al., 2015). Assess the client for any clinical manifestations of syphilis. If untreated, syphilis is a lifelong infection progressing in orderly

staging. The five stages of syphilis infection are (1) primary, (2) secondary, (3) early latent, (4) late latent, and (5) tertiary. The primary, secondary, and early latent stages are considered the most infectious: the estimated risk of per person transmission is 60%. Furthermore, in these stages, the fetus is at higher risk of acquiring maternal infections Klein et al., 2015).

FIGURE 5.6 Chancre of primary syphilis. (From Sweet, R. L., & Gibbs, R. S. [2005]. Atlas of infectious diseases of the female genital tract. Philadelphia, PA: Lippincott Williams & Wilkins.)

Primary syphilis is characterized by a chancre (painless ulcer) at the site of bacterial entry that will disappear within 1 to 6 weeks without intervention (Fig. 5.6). Motile spirochetes are present on dark-field examination of ulcer exudate. In addition, painless bilateral adenopathy is present during this highly infectious period. The client is highly infectious whenever chancres are present. If left untreated, the infection progresses to the secondary stage. Secondary syphilis appears 2 to 6 months after the initial exposure and is manifested by flu-like symptoms and a maculopapular rash of the trunk, palms, and soles. Alopecia and adenopathy are both common during this stage. In addition to rashes, secondary syphilis may present with symptoms of fever, pharyngitis, weight loss, and fatigue (Peterman et al., 2015). The secondary stage of syphilis lasts about 2 years. Once the secondary stage subsides, the latency periods (early and late) begin. These stages are characterized by the absence of any clinical manifestations of disease, although the serology is positive. This stage can last as long as 20 years. If not treated, tertiary or late syphilis occurs, with life-threatening heart disease and neurologic disease that slowly destroys the heart, with inflammation of the aorta, eyes, brain, central

nervous system, and skin. Clients with a diagnosis of HIV or another STI should be screened for syphilis, and all pregnant women should be screened at their first prenatal visit. Serologic testing for syphilis is evaluated by using both nontreponemal and treponemal tests. Nontreponemal tests measure immunoglobulin M (IgM) and immunoglobulin G (IgG). Although these tests are less specific, they are commonly used for primary screening because they are rapid to perform and inexpensive. The most commonly used nontreponemal tests are the rapid plasma regain (RPR) and the Venereal Disease Research Laboratory (VDRL) tests. Treponemal tests detect treponema-specific immunoglobulin A (IgA), IgM, and IgG antibodies, giving these tests a greater accuracy. Current treponemal tests include the EIA, fluorescent treponemal antibody absorption (FTA-ABS), T. pallidum agglutination assay (TPPA), and T. pallidum hemagglutination assay (TPHA) (Schuiling & Likis, 2016). A presumptive diagnosis can be made by using two serologic tests: • Nontreponemal tests (VDRL and RPR) • Treponemal tests (FTA-ABS and TP-PA). Dark-field microscopic examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis (CDC, 2015k).

Nursing Management of Herpes and Syphilis Genital ulcers from either herpes or syphilis can be devastating to women, and the nurse can be instrumental in helping her through this difficult time. Referral to a support group may be helpful. Address the psychosocial aspects of these STIs with women by discussing appropriate coping skills, acceptance of the lifelong nature of the condition (herpes), and options for treatment and rehabilitation. Nurses can help to ameliorate the misery, morbidity, and mortality associated with STIs through safe, accurate, sensitive, and supportive care. Teaching Guidelines 5.3 highlights appropriate teaching points for the client with genital ulcers.

Teaching Guidelines 5.3

CARING FOR GENITAL ULCERS

• Abstain from intercourse during the prodromal period and when lesions are present. • Wash hands with soap and water after touching lesions to avoid autoinoculation. • Use comfort measures such as wearing nonconstricting clothes, wearing cotton underwear, urinating in water if urination is painful, taking lukewarm sitz baths, and air-drying lesions with a hair dryer on low heat. • Avoid extremes of temperature such as ice packs or hot pads to the genital area as well as application of steroid creams, sprays, or gels. • Use condoms with all new or noninfected partners. • Inform health care professionals of your condition.

Pelvic Inflammatory Disease PID is a common and serious reproductive health disorder in which rates remain unacceptably high among adolescent girls and young adult women in the United States. It refers to an inflammatory state of the upper female genital tract and nearby structures. The fallopian tubes, ovaries, or peritoneum may be involved and endometriosis may also be present. PID results from an ascending polymicrobial infection of the upper female reproductive tract, frequently caused by untreated chlamydia or gonorrhea (Fig. 5.7). Annually, in the United States, the CDC (2015l) estimates that more than one million women experience an episode of acute PID. Up to 10% to 15% of these women may become infertile as a result of PID. A large proportion of the ectopic pregnancies, pelvic abscess formations, and chronic pelvic pain that occur every year is due to the consequences of PID (CDC, 2015l). It is a serious health problem in the United States, costing an estimated ∃10 billion annually in terms of hospitalizations and surgical procedures (Gilbert, 2015). All sexually active women are at risk for PID, but common risk factors include age less than 25 years, residence in an inner city, multiple sexual partners, sex with a new partner, insertion of an intrauterine contraceptive (IUC) within the past 6 weeks, vaginal douching, history of STI in the woman or her partner, lack of barrier contraceptive use, and a previous episode of PID. Women of African or African Caribbean ethnicity also have a higher reported prevalence of the condition (Simmons, 2015). Complications include fibrosis, scarring, loss of tubal function, ectopic pregnancy, pelvic abscess, infertility, recurrent or chronic episodes of the disease, chronic abdominal pain, pelvic adhesions, and depression (Simmons, 2015). Because of the seriousness of the complications of PID, an accurate diagnosis is critical.

FIGURE 5.7 Pelvic inflammatory disease. Chlamydia or gonorrhea spreads up the vagina into the uterus and then to the fallopian tubes and ovaries.

Therapeutic Management Broad-spectrum antibiotic therapy is generally required to cover chlamydia, gonorrhea, and/or any anaerobic infection. The current CDC recommendation (Blank, 2015) is: ceftriaxone 250 mg in a single injection plus doxycycline 100 mg twice a day for 14 days with or without metronidazole 500 mg orally, twice a day for 14 days, or cefoxitin 2 g intramuscularly in a single dose and probenecid 1 g orally administered concurrently in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days. PID in pregnancy is uncommon, but a combination of cefotaxime, azithromycin, and metronidazole for 14 days may be used. Tetracyclines and quinolones should be avoided during pregnancy (King et al., 2015). The client is treated on an ambulatory basis with a single-dose injectable antibiotic or is hospitalized and given antibiotics intravenously. The decision to hospitalize a woman is based on clinical judgment and the severity of her symptoms (e.g., severely ill with high fever, a tubo-ovarian abscess is suspected, the woman is immunocompromised or presents with protracted vomiting). Treatment then includes intravenous antibiotics, increased oral fluids to improve hydration, bed rest, and pain management. Follow-up is needed to validate that the infectious process has disappeared to prevent the development of chronic pelvic pain.

Nursing Assessment Nursing assessment of the woman with PID involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing. HEALTH HISTORY AND CLINICAL MANIFESTATIONS Explore the client’s current and past medical health history for risk factors for PID, which may include: • Adolescence or young adulthood • Non-White female • Having multiple sex partners • Early onset of sexual activity • History of PID or STI • Sexual intercourse at an early age • Alcohol or drug use • Having intercourse with a partner who has untreated urethritis • Recent insertion of an IUC • Nulliparity • Cigarette smoking • Recent termination of pregnancy • Lack of consistent condom use • Lack of contraceptive use • Douching • Prostitution Assess the client for clinical manifestations of PID, keeping in mind that, because of the wide variety of clinical manifestations of PID, clinical diagnosis can be challenging. To reduce the risk of missed diagnosis, the CDC has established criteria for the diagnosis of PID. Minimal criteria (all must be present) are lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness. Additional supportive criteria that support a diagnosis of PID are:

• Abnormal cervical or vaginal mucopurulent discharge • Oral temperature above 101°F (38.3°C) • Cervical motion tenderness • Elevated erythrocyte sedimentation rate (inflammatory process) • Elevated C-reactive protein level (inflammatory process) • N. gonorrhoeae or C. trachomatis infection documented (causative bacterial organism) • White blood cells on saline vaginal smear • Prolonged or increased menstrual bleeding • Dysmenorrhea • Dysuria • Acute lower abdominal pain • Painful sexual intercourse • Nausea • Vomiting (CDC, 2015l). PHYSICAL EXAMINATION AND LABORATORY AND DIAGNOSTIC TESTS Inspect the client for presence of fever (usually over 101°F [38.3°C]) or vaginal discharge. Palpate the abdomen, noting tenderness over the uterus or ovaries. Laparoscopy is the current criterion standard for the diagnosis of PID. No single test is highly specific or sensitive for the disease, but certain laboratory studies that can be used to support the diagnosis include the erythrocyte sedimentation rate, C-reactive protein, and chlamydial and gonococcal DNA probes and cultures (Simmons, 2015).

Nursing Management If the woman with PID is hospitalized, maintain hydration via intravenous fluids if necessary and administer analgesics as needed for pain. Semi-Fowler’s positioning facilitates pelvic drainage. A key element to treatment of PID is education to prevent recurrence. Depending on the clinical setting (hospital or community clinic) where the nurse encounters the woman diagnosed with PID, a risk assessment should be done to ascertain what interventions are appropriate to

prevent a recurrence. To gain the woman’s cooperation, explain the various diagnostic tests needed. Discuss the implications of PID and the risk factors for the infection; her sexual partner should be included if possible. Sexual counseling should include practicing safer sex, limiting the number of sexual partners, using barrier contraceptives consistently, avoiding vaginal douching, considering another contraceptive method if she has an IUC and has multiple sexual partners, and completing the course of antibiotics prescribed (Shepherd, 2015). Explain the serious sequelae that may occur if the condition is not treated or if the woman does not adhere to the treatment plan. Ask the woman to have her partner go for evaluation and treatment to prevent a repeat infection. Provide nonjudgmental support while stressing the importance of barrier contraceptive methods and follow-up care. Teaching Guidelines 5.4 gives further information related to PID prevention.

Teaching Guidelines 5.4

PREVENTING PELVIC INFLAMMATORY DISEASE • Advise sexually active girls and women to insist their partners use condoms. • Discourage routine vaginal douching, as this may lead to bacterial overgrowth. • Encourage regular STI screening. • Emphasize the importance of having each sexual partner receive antibiotic treatment.

VACCINE-PREVENTABLE STIs Some STIs can be effectively prevented through preexposure vaccination. Vaccines are under development or are undergoing clinical trials for certain STIs, including HIV and HSV. However, the only vaccines currently available are for prevention of hepatitis A, hepatitis B, and HPV infection. Vaccination efforts focus largely on integrating the use of these available vaccines into STI prevention and treatment activities (CDC, 2015g).

Human Papillomavirus HPV is the most common viral infection in the United States. HPV is so common that nearly all sexually active men and women will get at least one type of HPV at some point in their lives (CDC, 2015m). Genital warts or condylomata (Greek for “warts”) are caused by HPV. Conservative estimates suggest that in the United States, approximately 79 million people have productive HPV infection, and 14 million Americans acquire it annually (CDC, 2015m). Clinical studies have confirmed that HPV is the cause of essentially all cases of cervical cancer, which is the fourth most common cancer in women in the United States, following lung, breast, and colorectal cancer. Every year in the United States, over 12,000 women are diagnosed with cervical cancer, and about 4,000 women die from this disease. About 1% of sexually active men and women in the United States have genital warts at any given time (American Cancer Society [ACS], 2015). HPV-mediated oncogenesis is responsible for up to 95% of cervical squamous cell carcinomas and nearly all preinvasive cervical neoplasms (CDC, 2015m). More than 40 types of HPV can infect the genital tract. Types 16, 18, 31, 35, 39, 45, 51, 52, 58, 59, and 68 are associated with cervical dysplasia and may contribute to the development of anal, cervical, penile, and cancers (ACS, 2015). HPV is most prevalent in young women between the ages of 20 and 24 years, followed closely by the 15- to 19-year-old age group (Gearhart, Randall, Buckley, & Buckley, 2016).

Take Note! The lifetime risk of HPV infection is estimated to be as high as 50% in sexually active individuals.

Nursing Assessment Nursing assessment of the woman with HPV involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing. A woman with HPV lesions may have symptoms such as profuse, irritating vaginal discharge, itching, dyspareunia, or bleeding after intercourse. She may also report ’bumps’ on her labia. Physical inspection of the

external genitalia is important whenever HPV lesions are suspected or seen. HEALTH HISTORY AND CLINICAL MANIFESTATIONS Assess the client’s health history for risk factors for HPV, which include having multiple sex partners, age (15 to 25 years), sex with a male who has had multiple sexual partners, and first intercourse at age 16 or younger (Mohanty & Ghosh, 2015). Risk factors contributing to the development of cervical cancer include smoking, few or no screenings for cervical cancer, multiple sex partners, immunosuppressed state, long-term contraceptive use (more than 2 years), coinfection with another STI, pregnancy, nutritional deficiencies, and early onset of sexual activity (Gearhart, Higgins, Randall, & Buckley, 2016). Assess the client for clinical manifestations of HPV. Most HPV infections are asymptomatic, unrecognized, or subclinical. Visible genital warts usually are caused by HPV types 6 or 11. In addition to the external genitalia, genital warts can occur on the cervix and in the vagina, urethra, anus, and mouth. Depending on the size and location, genital warts can be painful, friable (easily pulverized or crumbled), and pruritic (itching), although most are typically asymptomatic (Fig. 5.8). The strains of HPV associated with genital warts are considered low risk for development of cervical cancer, but other HPV types (16, 18, 31, 33, and 35) have been strongly associated with cervical cancer (CDC, 2015m).

FIGURE 5.8 Genital warts. (Illustration provided by Anatomical Chart Co. Photograph from Gorbach, S. L., et al. [2004]. Infectious diseases. Philadelphia, PA: Lippincott Williams & Wilkins.)

PHYSICAL EXAMINATION AND LABORATORY AND DIAGNOSTIC TESTS Clinically, visible warts are diagnosed by inspection. The warts are fleshy papules with a warty, granular surface. Lesions can grow very large during pregnancy, affecting urination, defecation, mobility, and descent of the fetus

(CDC, 2015m). Large lesions, which may resemble cauliflowers, exist in coalesced clusters and bleed easily. Pap smears now are performed every 3 to 5 years for low-risk women. This current standard of care, calling for less frequent cervical cancer screening than in the past, makes it critical for women to understand when they are to have them and follow through to get them. These regular Pap smears will detect the cellular changes associated with HPV. The FDA has recently approved an HPV test as a follow-up for women who have an ambiguous Pap test. In addition, this HPV test may be a helpful addition to the Pap test for general screening of women aged 30 and over. The HPV test is a diagnostic test that can determine the specific HPV strain, which is useful in discriminating between low-risk and high-risk HPV types. A specimen for testing can be obtained with a fluid-phase collection system such as Thin Prep. The HPV test can identify 13 of the highrisk types of HPV associated with the development of cervical cancer and can detect high-risk types of HPV even before there are any conclusive visible changes to the cervical cells. If the test is positive for the high-risk types of HPV, the woman should be referred for colposcopy, which is a visual examination of the cervix using magnification and simple staining solutions such as acetic acid and Lugol’s solution. It is sometimes accompanied by a biopsy to confirm a cervical abnormality (Decker, McLachlin, & Lotocki, 2015). Upon physical examination, it is determined that Sandy has genital warts. The nurse finds out that Sandy engaged in high-risk behavior with a stranger she “hooked up” with recently at college. She couldn’t imagine that he would give her an STI because “he looked so clean-cut.” She wonders how she could possibly have genital warts. What information should be given to Sandy about STIs in general? What specific information about HPV should be stressed?

Therapeutic Management There is currently no medical treatment or cure for HPV. Instead, therapeutic management focuses heavily on prevention through the use of the HPV vaccine and education and on the treatment of lesions and warts caused by HPV. The FDA has approved three HPV vaccines to prevent cervical cancer: Cervarix, Gardasil, and Gardasil 9.

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended the vaccine for routine administration to 11- and 12-year-old girls and boys. This recommendation has created a firestorm from many parents feeling that such a vaccine would give young women a false sense of security and lead to promiscuity. Nurses may encounter parental resistance and will need to present the facts to parents about the effectiveness of the vaccines and prevention of cervical cancer. The ACIP also endorses the use of a HPV vaccine for girls and boys as young as age 9 and recommends that women between the ages of 13 and 26 receive the vaccination series, which consists of three injections over 6 months. All three are prophylactic HPV vaccines designed primarily for cervical cancer prevention. Cervarix is effective against HPV-16, -18, -31, -33, and -45, the five most common cancer-causing types, including most causes of adenocarcinoma for which we cannot screen adequately. Gardasil is effective against HPV-16, -18, and -31, three common squamous cell cancercausing types. In addition, Gardasil is effective against HPV-6 and -11, causes of genital warts and respiratory papillomatosis. The most important determinant of vaccine impact to reduce cervical cancer is its duration of efficacy. To date, Cervarix’s efficacy is proven for 6.4 years and Gardasil’s for 5 years (CDC, 2015n). Gardasil 9 is effective against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. According to the FDA, the new vaccine (Gardasil 9) can potentially prevent about 90% of cervical, vulvar, vaginal, and anal cancers (Gearhart, Higgins, Randall, & Buckley, 2016). Prophylactic HPV vaccines are safe, well tolerated, and highly efficacious in preventing persistent infections and cervical diseases associated with vaccine-HPV types among young females. However, long-term efficacy and safety need to be addressed in the future (Castle & Schmeler, 2015). The vaccine is administered intramuscularly in three separate 0.5-mL doses. The first dose may be given to any individual 9 to 26 years old prior to infection with HPV. The second dose is administered 2 months after the first, and the third dose is given 6 months after the initial dose. The deltoid region of the upper arm or anterolateral area of the thigh may be used. The most common vaccine side effects include pain, fainting, redness, and swelling at the injection site; fatigue; headache; muscle and joint aches; and gastrointestinal distress. Serious adverse events reported to the CDC include blood clots occurring in the heart, lungs, or legs, Guillain–Barré syndrome, and less than 30 deaths (CDC, 2015n). Most client profiles had risk factors that may have attributed to these adverse events and not to the vaccine alone (CDC, 2015n).

If the woman does not receive primary prevention with the vaccine, then secondary prevention would focus on education about the importance of receiving regular Pap smears and, for women over age 30, including an HPV test to determine whether the woman has a latent high-risk virus that could lead to precancerous cervical changes. Finally, treatment options for precancerous cervical lesions or genital warts caused by HPV are numerous and may include: • Topical trichloroacetic acid (TCA) 80% to 90% • Liquid nitrogen cryotherapy • Topical imiquimod 5% cream (Aldara) • Topical podophyllin 10% to 25% • Laser carbon dioxide vaporization • Client-applied Podofilox 0.5% solution or gel • Simple surgical excision • Loop electrosurgical excisional procedure (LEEP) • Intralesional interferon therapy (King et al., 2015) The goal of treating genital warts is to remove the warts and induce wart-free periods for the client. Treatment of genital warts should be guided by the preference of the client and available resources. No single treatment has been found to be ideal for all clients, and most treatment modalities appear to have comparable efficacy. Because genital warts can proliferate and become friable during pregnancy, they should be removed using a local agent. A cesarean birth is not indicated solely to prevent transmission of HPV infection to the newborn, unless the pelvic outlet is obstructed by warts (Gearhart, Higgins, Randall, & Buckley, 2016).

Nursing Management An HPV infection has many implications for the woman’s health, but most women are unaware of HPV and its role in cervical cancer. The average age of sexual debut is in early adolescence; therefore, it is important to target this population for use of the HPV/cervical cancer vaccine. Key nursing roles are teaching about prevention of HPV infection and promotion of vaccines and screening tests in order to reduce the morbidity and mortality associated with cervical cancer caused by HPV infection. Teach all

women that the only way to prevent HPV is to refrain from any genital contact with another individual. Although the effect of condoms in preventing HPV infection is unknown, latex condom use has been associated with a lower rate of cervical cancer. Teach women about the link between HPV and cervical cancer. Explain that, in most cases, there are no signs or symptoms of infection with HPV. Strongly encourage all young women between the ages of 9 and 26 (and in the case of young girls between 9 and 18, their parents) to consider receiving the vaccine against HPV. For all women, promote the importance of obtaining regular Pap smears and, for women over age 30, suggest an HPV test to rule out the presence of a latent high-risk strain of HPV. Education and counseling are important aspects of managing women who have genital warts. Teach the woman that: • Even after genital warts are removed, HPV still remains and viral shedding will continue. • The likelihood of transmission to future partners and the duration of infectivity after treatment for genital warts are unknown. • The recurrence of genital warts within the first few months after treatment is common and usually indicates recurrence rather than reinfection (CDC, 2015m). In the absence of major national health policy mandates, a multilevel, multifaceted approach will be needed to achieve high rates of HPV vaccination in the United States. Nurses need to focus on the education of their clients regarding indications of HPV vaccination and work on approaches to communicating most effectively with parents about the safety and benefits of vaccination and the risks associated with not vaccinating their children. Sandy is being treated for HPV and is anxious for her “things” to disappear and never return. What education is needed to prevent further transmission from Sandy to any future sexual partners?

Hepatitis A and B Hepatitis is an acute, systemic, viral infection that can be transmitted sexually. The viruses associated with hepatitis or inflammation of the liver are hepatitis A, B, C, D, E, and G. Hepatitis A is an inflammation of the liver caused by infection with the hepatitis A virus (HAV). Hepatitis A is highly contagious and spreads primarily through the fecal–oral route from person-to-person or by ingesting contaminated food or water. Hepatitis A can also be transmitted through sexual intercourse. Person-to-person transmission through the fecal–oral route (i.e., ingestion of something that has been contaminated with the feces of an infected person) is the primary means of HAV transmission in the United States (CDC, 2015o). Most infections result from close personal contact with an infected household member or sex partner. A HAV infection produces a selflimited disease that does not result in chronic infection or chronic liver disease, but it can be easily passed on to others within the same household. The hepatitis B virus (HBV) is transmitted by infected body fluids through saliva, blood serum, semen, menstrual blood, and vaginal secretions, and through activities that involve percutaneous (i.e., puncture through the skin) or mucosal contact with infectious blood or body fluids (e.g., semen, saliva). Transmission also occurs via having sex with an infected partner; injection-drug use that involves sharing needles, syringes, or drug-preparation equipment; birth to an infected mother; contact with the blood or open sores of an infected person; needle sticks or sharp instrument exposures; or sharing items such as razors or sharing toothbrushes with an infected person. HBV is not spread through food or water, sharing eating utensils, breast-feeding, skin-to-skin contact, coughing, or sneezing (CDC, 2015p). The WHO estimates that globally about 2 billion people have been infected with HBV and that more than 240 million have chronic (long-term) liver infections as a result. Worldwide, hepatitis B has the highest death rate (780,000 annually) of any STI except HIV (WHO, 2015a). Risk factors for infection include having multiple sex partners, engaging in unprotected receptive anal intercourse, and having a history of other STIs (CDC, 2015p). The most effective means to prevent the transmission of hepatitis A or B is preexposure immunization. Vaccines are available for the prevention of HAV and HBV, both of which can be transmitted sexually. Every person seeking treatment for an STI should be considered a candidate for HBV vaccination, and some individuals

(e.g., men who have sex with men, and injection-drug users) should be considered for HAV vaccination (CDC, 2015p).

Therapeutic Management Unlike other STIs, HAV and HBV are preventable through immunization. HAV is usually self-limiting and does not result in chronic infection. HBV can result in serious, permanent liver damage. Treatment is generally supportive. No specific treatment for acute HBV infection exists.

Nursing Assessment Assess the client for clinical manifestations of hepatitis A and B. Hepatitis A produces flu-like symptoms with malaise, fatigue, anorexia, nausea, pruritus, fever, and upper right quadrant pain. Symptoms of hepatitis B are similar to those of hepatitis A, but with less fever and skin involvement. The diagnosis of hepatitis A cannot be made based on clinical manifestations alone and requires serologic testing. The presence of IgM antibody to HAV is diagnostic of acute HAV infection. Hepatitis B is detected by a blood test that looks for antibodies and proteins produced by the virus and are positively diagnosed by the presence of hepatitis B surface antigen (HBsAg) (Pyrsopoulos & Reddy, 2015).

Nursing Management Nurses should encourage all women to be screened for hepatitis when they have their annual Pap smear, or sooner if high-risk behavior is identified. Nurses should also encourage women to undergo HBV screening at their first prenatal visit and repeat screening in the last trimester for women with high-risk behaviors to comply with USPSTF (2015) recommendations. Nurses can also explain that hepatitis B vaccine is given to all infants after birth in most hospitals. The vaccination consists of a series of three injections given within 6 months. The vaccine has been shown to be safe and well tolerated by most recipients (CDC, 2015p). Hepatitis A vaccine is strongly encouraged for children between 12 and 23 months of age; persons 1 year of age and older traveling to countries with a high prevalence of hepatitis A, such as Central or South America, Mexico, Asia, Africa, and eastern Europe; men who have sex with men; persons who use street drugs; and persons with chronic liver disease (CDC, 2015o). For others, hepatitis A vaccine series (two doses 6 months apart) may be

started whenever a person is at risk for infection.

Hepatitis C Hepatitis C is an infection caused by the hepatitis C virus (HCV) that attacks the liver and leads to inflammation. It is estimated that about 3% of the world’s population has been infected with HCV and that there are more than 170 million chronic carriers who are at risk for developing liver cirrhosis and/or liver cancer (WHO, 2015e). Although HCV is not usually transmitted sexually, it deserves a brief mention here because injection-drug use by women places them at risk for it. HCV-infected pregnant women have a 2% to 8% risk of viral transmission to their newborn, but the mechanism and timing of mother-to-fetus transmission are not fully understood. Although the typical transmission of HCV is not sexual, it can be transmitted sexually. Those with the virus are instructed to refrain from unprotected sexual activity. Women at high risk include those with a history of injection-drug use, health care workers, and those with a history of blood transfusion before 1992 (Dhawan, 2015). The prevalence of HCV infection in pregnant women is approximately 1%. The majority of infected women are not aware they have HCV because they are not clinically ill. Perinatal transmission of HCV is relatively rare, except in women who are immunocompromised (e.g., have HIV/AIDS). A timely diagnosis of HIV and HCV is needed to start treatment, with the best option is to treat HCV before pregnancy (Snijdewind et al., 2015). Hepatitis infections continue to be an important public health challenge. These viruses impact the entire age spectrum from newborns to the older population. Nurses from all disciplines may, therefore, encounter hepatitis-infected clients. As such, all nurses have a unique opportunity to prevent new infections through client education and improve health outcomes for those already infected.

ZIKA VIRUS DISEASE Zika virus is transmitted to humans primarily through the bite of an infected Aedes species mosquito during the daytime. The most common symptoms of Zika are fever, rash, headaches, bone pains, joint tenderness, and conjunctivitis. The illness is typically mild with symptoms lasting for several days to a week after being bitten. Up to 80% of people infected with the virus have no symptoms (CDC, 2016). The virus is in the Caribbean as well as parts of Central and South America. The virus has been reported to be spread through blood transfusions, sexual contact and can also be passed from a pregnant woman to her fetus and has been linked to a serious birth defect of the brain termed microcephaly. The CDC, WHO, and other scientific organizations are working to understand this possible link. In 2016 the World Health Organization declared Zika virus a public health emergency of international concern. The CDC recommends abstaining from oral, anal, or vaginal sexual contact with anyone who has traveled to areas with active infections. Pregnant women are also discouraged from traveling to regions with active infections (2016). At this time, there is no vaccine given to prevent Zika, or anti-viral medication to treat the infection. Prevention measures would include better housing construction, use insect repellents, wear long-sleeved shirts and pants, regular use of air conditioning, use of window screens, avoid traveling to mosquito-infested areas, and state and local mosquito control efforts.

ECTOPARASITIC INFECTIONS Ectoparasites are a common cause of skin rash and pruritus throughout the world, affecting persons of all ages, races, and socioeconomic groups. Overcrowding, global traveling, immigration, delayed diagnosis and treatment, and poor public education contribute to the prevalence of ectoparasites in both industrial and nonindustrial nations. Approximately 300 million ectoparasitic cases are reported worldwide each year (CDC, 2015g). These infections include infestations of scabies and pubic lice. Because these parasites are easily passed from one person to another during sexual intimacy, clients should be assessed for them when receiving care for other STIs. Scabies is an intensely pruritic dermatitis caused by a mite. The worldwide prevalence has been estimated at about 100 million cases annually (Monsel & Chosidow, 2015). In general, transmission occurs by direct skin-to-skin contact. The female mite burrows under the skin and deposits eggs, which hatch. The lesions start as a small papule that reddens, erodes, and sometimes crusts. Diagnosis is based on history and appearance of linear burrows in the webs of the fingers, on the elbows, in the axillae, buttocks, and the genitalia (Mutasim, 2015). Aggressive infestation can occur in immunodeficient, debilitated, or malnourished people, but healthy people do not usually suffer sequelae. Scabies treatment includes topical administration of a scabicidal agent (e.g., permethrin, crotamiton, or ivermectin), as well as an antibiotic if a secondary infection is present. Lice are parasitic insects that can be found on people’s head, body or pubic areas. Clients with pediculosis pubis (pubic louse) usually seek treatment because of the pruritus, because of a rash brought on by skin irritation from scratching, or because they notice lice or nits in their pubic hair, axillary hair, abdominal and thigh hair, and sometimes in the eyebrows, eyelashes, and beards. Infestation is usually asymptomatic until after a week or so, when bites cause pruritus and secondary infections from scratching (Fig. 5.9). Diagnosis is based on history and the presence of nits (small, shiny, yellow, oval, dewdrop-like eggs) affixed to hair shafts or lice (a yellowish, oval, wingless insect) (Guenther & Maguiness, 2015). Treatment has two aspects: medication and environmental control measures. Medications used include topical anti-louse agents such as permethrin shampoos,

malathion, spinosad, or ivermectin. Bedding and clothing should be washed in hot water and dried using a hot setting on the dryer; dry cleaning or sealing clothes in plastic bags for 2 weeks to decontaminate them. Sexual partners should also be treated, as well as family members who live in close contact with the infected person.

FIGURE 5.9 Pubic lice. A small brown living crab louse is seen at the base of hairs (arrow). (From Goodheart, H. [2009]. Goodheart’s photoguide of common skin disorders. Philadelphia, PA: Lippincott Williams & Wilkins.)

Nursing care of a woman infested with lice or scabies involves a three-tiered approach: eradicating the infestation with medication, removing nits, and preventing spread or recurrence by managing the environment. The CDC recommends regimens using pyrethrins and permethrins. Frequently, a combination of malathion or ivermectin is also added. Nurses should provide education about these products (Teaching Guidelines 5.5). The nurse can follow these same guidelines to prevent the health care facility from becoming infested.

Teaching Guidelines 5.5

TREATING AND MINIMIZING THE SPREAD OF SCABIES AND PUBIC LICE • Use the medication according to the manufacturer’s instructions. • Remove nits with a fine-toothed nit comb. • Do not share any personal items with others or accept items from others.

• Treat objects, clothing, and bedding and wash them in hot water. • Meticulously vacuum carpets to prevent a recurrence of infestation.

HUMAN IMMUNODEFICIENCY VIRUS Many advances have been made in the prevention of HIV transmission and management of HIV/AIDS since the virus was discovered in the early 1980s. Since that time, AIDS has claimed more than 40 million lives (WHO, 2015b). One of the most important discoveries has been antiretroviral treatment, which can halt the replication of the virus and ease symptoms, turning AIDS into a chronic condition instead of a rapidly terminal illness. Despite advances, HIV remains a major public health challenge today. Globally, an estimated 35 million people are infected or living with HIV, of which 22.5 million are in sub-Saharan Africa. In addition, of the 2.5 million children in the world estimated to be living with HIV, 2.3 million are in subSaharan Africa (WHO, 2015b). In the United States, an estimated 1.2 million people currently live with HIV, with almost one in six unaware of their infections. An estimated 50,000 new HIV infections occur annually; typically, every 10 minutes a person in the United States becomes infected with HIV (CDC, 2015q). In terms of epidemiology, fatality rate, and its social, legal, ethical, and political aspects, HIV/AIDS is a public health crisis and has generated more concern than any other infectious disease in modern medical history. The course of HIV infection is characterized primarily by latency. Unfortunately, profound immune suppression eventually develops and the illness is lethal. More than 650,000 people have died of AIDS in the United States since the 1980s (CDC, 2015q). HIV/AIDS continues to outpace the science, financing, prevention, and treatment efforts of the past quarter century. The economic impact of HIV/AIDS presents huge challenges. While the causality between poverty and HIV is not clear, it is certain that HIV pushes households and individuals into poverty. While many illnesses create catastrophic expenditures that can result in poverty, HIV/AIDS is among the worst because its victims are ill for a prolonged period of time before they die, and many are the chief household income earners. According to the WHO, the lower a person’s socioeconomic status is, the worse the health outcomes for them. An intervention to address this issue is to help women’s vocational development and economic empowerment since the illness exists for years (Conyers et al., 2015). To date, there is no cure for this fatal viral infection.

The HIV virus is transmitted by intimate sexual contact; by sharing needles for intravenous drug use; from mother to fetus during pregnancy or breastfeeding; and by transfusion of blood or blood products. Men who have sex with men represent the largest proportion of new infections, followed by men and women infected through heterosexual sex (CDC, 2015q). Among racial/ethnic groups in the United States, African Americans are at the highest risk of acquiring HIV/AIDS, and account for 45% of new HIV infections. The African American community continues to be ravaged by HIV/AIDS infection, despite the marked expenditures utilized to reduce incidence among this cohort. Efforts to produce culturally appropriate programs that work continue to elude officials, and HIV/AIDS has become pandemic within this racial/ethnic group. More awareness of HIV/AIDS using media campaigns is needed to reduce risky behaviors (Nunn et al., 2015). The number of women with HIV infection and AIDS has been increasing steadily worldwide. Today, women account for one in four (25%) new HIV infections in the United States. Women of color have been especially hard hit and represent the majority of women living with the disease and newly infected ones. Most women are infected through heterosexual sex (Kaiser Family Foundation, 2015). The WHO estimates that over 25 million women are living with HIV/AIDS worldwide, accounting for approximately 50% of the 40 million adults living with HIV/AIDS (CDC, 2015r). HIV disproportionately affects African American and Hispanic women: together they represent less than 25% of all women in the United States; yet they account for more than 82% of AIDS cases among women (CDC, 2015r). African American women in this country suffer disproportionately from the HIV/AIDS epidemic, as they acquire new HIV infections at nearly 15 times the rate of White women (CDC, 2015r). Women are particularly vulnerable to heterosexual transmission of HIV as a result of substantial mucosal exposure to seminal fluids. This biologic fact amplifies the risk of HIV transmission when coupled with the high prevalence of nonconsensual sex, sex without condoms, and the unknown and/or high-risk behaviors of their partners (CDC, 2015r). Therefore, the face of HIV/AIDS is becoming the face of young women. That shift will ultimately exacerbate the incidence of HIV because women spread it not only through sex, but also through nursing and childbirth. AIDS is a breakdown in the immune function caused by HIV, a retrovirus. A sufficient quantity of viruses must be transferred to infect a person. The virus cannot live long outside the human body; it cannot be transmitted via tears or

sweat. The HIV infection is associated with continued activation of immune system and is the driving force behind CD4 T cell depletion and progression to AIDS. The infected person develops opportunistic infections or malignancies that become fatal. Progression from HIV infection to AIDS occurs at a median of 11 years after infection (Bharaj & Chahar, 2015). HIV transmission modalities include the following: • Sexual intercourse with an infected partner unprotected by condoms • Blood transfusions from infected donors or organ transplants from infected donors • Needle sticks from contaminated sharps or sharing needles with infected people • Mother-to-infant during pregnancy, childbirth or breastfeeding More than 30 years have passed since HIV/AIDS began to affect our society. Since then, 50 million people have been infected by the virus, with AIDS being the fourth leading cause of death globally (CDC, 2015q). The morbidity and mortality of HIV continue to hold the attention of the medical community. While there has been a dramatic improvement in both morbidity and mortality with the use of highly active antiretroviral therapy, the incidence of HIV infection continues to rise.

Take Note! More than 90% of individuals infected with HIV worldwide do not know they are infected and, thus, are at risk of spreading it sexually to others (CDC, 2015q). The fetal and neonatal effects of acquiring HIV through perinatal transmission are devastating and eventually fatal. An infected mother can transmit HIV infection to her newborn before or during birth and through breast-feeding. Most cases of mother-to-child HIV transmission, the cause of more than 90% of pediatric-acquired infections worldwide, occur late in pregnancy or during delivery. Transmission rates vary from 25% in untreated non–breast-feeding populations in industrialized countries to about 40% among untreated breastfeeding populations in developing countries (Castel, Magnus, & Greenberg,

2015). Despite the dramatic reduction in perinatal transmission, hundreds of infants will be born infected with HIV.

HIV and Adolescents The effects of HIV and AIDS on adolescents and young adults is of increasing concern, but it is difficult to get accurate data because of the varying ways in which this population seeks health care services. Some adolescents continue to receive care through pediatricians and adult services, but many do not have access to health care. HIV infections are increasing in adolescents and young adults aged 13 to 24 years. Approximately 25% of cases of STIs reported in the United States each year are among teenagers. More than two million adolescents between the ages of ten and nineteen are living with HIV, and many do not receive the care and support they need to stay in good health. This is particularly significant because the risk of HIV transmission increases substantially if either partner is infected with an STI (WHO, 2015c). At least one adolescent in the United States is infected with HIV each hour. Since it takes an average of 11 years for AIDS symptoms to appear when HIV is left untreated, it is obvious that many adults with AIDS were infected as adolescents. Nurses can play a key role in preventing and controlling HIV infection by promoting risk reduction counseling and offering routine HIV testing to adolescents. Most sexually active youth do not feel that they are at risk for contracting HIV and have never been tested. Obtaining a sexual history and creating an atmosphere that promotes nonjudgmental risk counseling is a key component of the adolescent visit. In light of increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the CDC (2015q) recommends universal and routine HIV testing for all clients seen in health care settings who are 13 to 64 years of age.

Clinical Manifestations HIV infection undergoes three distinct phases: acute seroconversion, asymptomatic infection, and then progression to AIDS. When a person is initially infected with HIV, he or she goes through an acute primary infection period for about 3 weeks. The HIV viral load drops rapidly because the host’s immune system works well to fight this initial infection. The onset of the acute primary infection occurs 2 to 6 weeks after exposure. Symptoms include fever, pharyngitis, rash, and myalgia. Most people do not associate this flu-like condition with HIV infection. After initial exposure, there is a period of 3 to 12 months before seroconversion. The person is considered infectious during this time. After the acute phase, the infected person becomes asymptomatic, but the HIV virus begins to replicate. Even though there are no symptoms, the immune system runs down. A normal person has a CD4 T-cell count of 450 to 1,200 cells per microliter. When the CD4 T-cell count reaches 200 or less, the person is considered to have AIDS. The immune system begins a constant battle to fight this viral invasion, but over time it falls behind. A viral reservoir occurs in T cells that can store various stages of the virus. The onset and severity of the disease correlate directly with the viral load: the more HIV virus that is present, the worse the person will feel. As profound immunosuppression begins to occur, an opportunistic infection will occur, qualifying the person for the diagnosis of AIDS. As of now, AIDS will eventually develop in everyone who is HIV positive. The WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more client-friendly ART drugs, and prolonged use of ART drugs to reduce the risk of mother-to-child transmission of HIV. ART should be started when the CD4 counts are below 350 cells/microliter. Further recommendations include initiation of ART irrespective of CD4 cell count or clinical stage for people co-infected with active tuberculosis or hepatitis B with severe liver disease, pregnant women in serodiscordant partnerships, and children under 5 years of age (Bennett & Gilroy, 2015).

Diagnosis Several types of tests are approved to detect HIV. These tests are designed to detect antigens, antibodies, or RNA. The enzyme-linked immunosorbent assay (ELISA) is used as the initial screening test to determine presence of the HIV virus. When ELISA generates a positive result, a confirmation test (Western blot test) is then performed. In addition, several point-of-care or rapid antibody tests are available. Two categories of screening methods are currently used: rapid HIV tests and confirmatory tests. The rapid tests allow for screening at the point-ofcare and quick results. Five rapid HIV tests that are FDA approved include: (1) OraQuick Advance HIV tests (whole blood used); (2) Uni-Gold Recombigen HIV test (whole blood used); (3) Reveal G-3 Rapid HIV Antibody test (serum or plasma used); (4) Multispot (serum or plasma used); and (5) Clearview Stat-Pak and complete (whole blood used). A positive result is followed up with one of two confirmatory tests: Western blot (WB) or immunofluorescence (IFA) (Shafiee et al., 2015). Quick tests for HIV produce results in 10 to 20 minutes and also lower the health care worker’s risk of occupational exposure by eliminating the need to draw blood. The CDC’s Advancing HIV Prevention initiative, launched in 2003, has made increased testing a national priority. The CDC recommends HIV screening of all US residents aged 13 to 64 years in all health care settings (CDC, 2015r). Fewer than half of adults between the ages of 18 and 64 have ever had an HIV test, according to the CDC. The agency estimates that one fourth of the million HIV-infected people in the United States do not know they are infected. This means they are not receiving treatment that can prolong their lives, and they may be unknowingly infecting others. In addition, even when people do get tested, one in three fails to return to the testing site to learn their results when there is a 2-week wait. The CDC hopes that the new “one-stop” approach to HIV testing will change that pattern. People who are infected with HIV but not aware of it are not able to take advantage of the therapies that can keep them healthy and extend their lives, nor do they have the knowledge to protect their sex or drug-use partners from becoming infected. Knowing whether one is positive or negative for HIV confers great benefits in healthy decision-making. Rapid point-of-service HIV tests are becoming powerful screening tools in

various health care settings because they offer the opportunity to not only screen for HIV, but also to educate the person regarding risk factors, and discuss their test results—all in one clinical visit. Most use a fingerstick drop of blood or a swab of saliva taken from the mouth. Results are typically ready within 10 to 20 minutes. If the confirmation test (WB or IFA) is positive, the person is infected with HIV and is capable of transmitting the virus to others. HIV antibody is detectable in at least 95% of people within 3 months after infection (CDC, 2015q).

Therapeutic Management The goals of HIV drug therapy are as follows: • Decrease the HIV viral load below the level of detection. • Restore the body’s ability to fight off pathogens. • Improve the client’s quality of life. • Reduce HIV morbidity and mortality (Bennett & Gilroy, 2015). Highly active antiretroviral therapy (HAART), which combines at least three antiretroviral drugs, has dramatically improved the prognosis of HIV/AIDS. Often treatment begins with combination HAART at the time of the first infection, when the person’s immune system is still intact. The current HAART standard is a triple combination therapy, but some clients may be given a fourth or fifth agent. Current therapy to prevent the transmission of HIV to the newborn includes a three-part regimen: 1. The mother takes an oral antiretroviral agent at 14 to 34 weeks of gestation; it is continued throughout pregnancy. 2. During labor, an antiretroviral agent is administered intravenously until delivery. 3. An antiretroviral syrup is administered to the infant within 12 hours after birth. Dramatic new treatment advances with antiretroviral medications have turned a disease that used to be a death sentence into a chronic, manageable one for individuals who live in countries where ART is available. Despite these advances in treatment, however, only a minority of HIV-positive people in the United States who take antiretroviral medications are receiving the full benefits because they are not adhering to the prescribed regimen. Successful ART requires nearly perfect adherence to a complex medication regimen; less-thanperfect adherence leads to drug resistance (King et al., 2015). Adherence is difficult because of the complexity of the regimen and the lifelong duration of treatment. A typical antiretroviral regimen may consist of three or more medications taken twice daily. Adherence is made even more

difficult because of the unpleasant side effects, such as nausea and diarrhea. Women in early pregnancy already experience these, and the antiretroviral medication only exacerbates them.

Nursing Management Nurses can play a major role in caring for the HIV-positive woman by helping her accept the possibility of a shortened life span, cope with others’ reactions to a stigmatizing illness, and develop strategies to maintain her physical and emotional health. Educate the woman about changes she can make in her behavior to prevent spreading HIV to others, and refer her to appropriate community resources such as HIV medical care services, substance abuse services, mental health services, and social services. See Nursing Care Plan 5.1: Overview of the Woman Who Is HIV Positive.

Providing Education About Drug Therapy The goal of antiretroviral therapy is to suppress viral replication so that the viral load becomes undetectable by diagnostic tests. This is done to preserve immune function and delay disease progression but is a challenge because of the side effects of nausea and vomiting, diarrhea, altered taste, anorexia, flatulence, constipation, headaches, anemia, and fatigue. Although not everyone experiences all of the side effects, the majority do have some of them. Current research has not documented the long-term safety of exposure of the fetus to antiretroviral agents during pregnancy, but collection of data is ongoing. Help to reduce the development of drug resistance and thus treatment failure by identifying the barriers to adherence; identifying these barriers can help the woman to overcome them. Some of the common barriers exist because the woman: • Does not understand the link between drug resistance and nonadherence • Fears revealing her HIV status by being seen taking medication • Has not adjusted emotionally to the HIV diagnosis • Does not understand the dosing regimen or schedule • Experiences unpleasant side effects frequently • Feels anxious or depressed (Dubin, 2015) Educate the woman about the prescribed drug therapy and stress that it is very important to take the regimen as prescribed. Offer suggestions about how to cope with anorexia, nausea, and vomiting by: • Separating the intake of food and fluids • Eating dry crackers upon arising • Eating six small meals daily • Using high-protein supplements (Boost, Ensure) to provide quick and easy protein and calories • Eating “comfort foods,” which may appeal when other foods do not

Promoting Adherence to Therapy Remaining adherent to drug therapy is a huge challenge for many HIV-infected

people. Adherence becomes difficult when the same pills that are supposed to thwart the disease are making the person sick. Nausea and diarrhea are just two of the possible side effects. It is often difficult to increase the client’s quality of life when so much oral medication is required. The combination medication therapy is challenging for many people, and staying compliant over a period of years is extremely difficult. Stress the importance of taking the prescribed antiretroviral drug therapies by explaining that they help prevent replication of the retroviruses and subsequent progression of the disease and also decrease the risk of perinatal transmission of HIV. In addition, provide written materials describing diet, exercise, medications, and signs and symptoms of complications and opportunistic infections. Reinforce this information at each visit.

Preventing HIV Infection Despite the available information about HIV infection and AIDS, it causes great anxiety and fear of the unknown. It is vital to take a leadership role in educating the public about risky behaviors in the fight to control this disease. The core of HIV prevention is to reduce the number of sexual contacts and to use condoms. This is all good advice for many women, but some simply do not have the economic and social power or choices or control over their lives to put that advice into practice. Recognize that fact, and address the factors that will give women more control over their lives by providing anticipatory guidance, giving ample opportunities to practice negotiation techniques and refusal skills in a safe environment, and encouraging the use of female condoms to protect against this deadly virus. Prevention is the key to reversing the current infection trends.

NURSING CARE PLAN 5.1 Overview of the Woman Who is HIV Positive Annie, a 28-year-old African American woman, is HIV-positive. She acquired HIV through unprotected sexual contact. She has been inconsistent in taking her antiretroviral medications and presents today stating she is tired and does not feel well. NURSING DIAGNOSIS: Risk for infection related to positive HIV status and inconsistent adherence to antiretroviral therapy regimen Outcome Identification and Evaluation The client will remain free of opportunistic infections as evidenced by temperature within acceptable parameters and absence of signs and symptoms of opportunistic infections. Interventions: Minimizing the Risk of Opportunistic Infections • Assess CD4 count and viral loads to determine disease progression (CD4 counts 10,000 copies/L = increased risk for opportunistic infections). • Assess complete blood count to identify presence of infection (>10,000 cells/mm3 may indicate infection). • Assess oral cavity and mucous membranes for painful white patches in mouth to evaluate for possible fungal infection. • Teach client to monitor for general signs and symptoms of infections, such as fever, weakness, and fatigue, to ensure early identification. • Provide information explaining the importance of avoiding people with infections when possible to minimize risk of exposure to infections. • Teach importance of keeping appointments so her CD4 count and viral load can be monitored to alert the health care provider about her immune system status. • Instruct her to reduce her exposure to infections via: • Meticulous hand hygiene • Thorough cooking of meats, eggs, and vegetables

• Wearing shoes at all times, especially when outdoors • Encourage a balance of rest with activity throughout the day to prevent overexertion. • Stress importance of maintaining prescribed antiretroviral drug therapies to prevent disease progression and resistance. • If necessary, refer Annie to a nutritionist to help her understand what constitutes a well-balanced diet with supplements to promote health and ward off infection. NURSING DIAGNOSIS: Deficient knowledge related to HIV infection and possible complications Outcome Identification and Evaluation The client will demonstrate increased understanding of HIV infection as evidenced by verbalizing appropriate health care practices and adhering to therapy and reduce her risk of further exposure and reduce risk of disease progression. Interventions: Providing Client Education • Assess her understanding of HIV and its treatment to provide a baseline for teaching. • Establish trust and be honest with Annie; encourage her to talk about her fears and the impact of the disease to provide an outlet for her concerns. Encourage her to discuss reasons for her nonadherence to therapy. • Provide a nonjudgmental, accessible, confidential, and culturally sensitive approach to promote Annie’s self-esteem and allow her to feel that she is a priority. • Explain measures, including safer sex practices and birth control options, to prevent disease transmission; determine her willingness to practice safer sex to protect others to determine further teaching needs. • Discuss the signs and symptoms of disease progression and potential opportunistic infections to promote early detection for prompt intervention. • Outline with the client the availability of community resources and make appropriate referrals as needed to provide additional education and support. • Encourage Annie to keep scheduled appointments to ensure follow-up and allow early detection of potential problems.

Providing Care During Pregnancy and Childbirth Voluntary counseling and HIV testing should be offered to all pregnant women as early in the pregnancy as possible to identify HIV-infected women so that treatment can be initiated early. Once a pregnant woman is identified as being HIV positive, she should be informed about the risk for perinatal infection. Current evidence indicates that in the absence of antiretroviral medications, 25% of infants born to HIV-infected mothers will become infected with HIV (CDC, 2015q). If women do receive a combination of antiretroviral therapies during pregnancy, however, the risk of HIV transmission to the newborn drops below 2% (Castel, Magnus, & Greenberg, 2015). In addition, HIV can be spread to the infant through breast-feeding, and thus all HIV-infected pregnant women should be counseled to avoid breast-feeding and use formula instead. A recent maternal infection with HIV may raise the risk of transmission through breast-feeding to twice that of a woman with earlier established infection, probably as a result of the high viral load associated with recent infection (Koletzko, 2015). In addition, the woman needs instructions on ways to enhance her immune system by following these guidelines during pregnancy: • Getting adequate sleep each night (7 to 9 hours) • Avoiding infections (e.g., staying out of crowds, good hand hygiene) • Decreasing stress in her life • Consuming adequate protein and vitamins • Increasing her fluid intake to 2 liters daily to stay hydrated • Planning rest periods throughout the day to prevent fatigue As said earlier, despite the dramatic reduction in perinatal transmission, hundreds of infants will be born infected with HIV. The birth of each infected infant is a missed prevention opportunity. To minimize perinatal HIV transmission, identify HIV infection in women, preferably before pregnancy; provide information about disease prevention; and encourage HIV-infected women to follow the prescribed drug therapy.

Providing Appropriate Referrals The HIV-infected woman may have difficulty coping with the normal activities of daily living because she has less energy and decreased physical endurance. She may be overwhelmed by the financial burdens of medical and drug therapies, the emotional responses to a life-threatening condition, and, if she is pregnant, concern about her infant’s future. A case management approach is needed to deal with the complexity of her needs during this time. Be an empathetic listener and make appropriate referrals for nutritional services, counseling, homemaker services, spiritual care, and local support groups. Many community-based organizations have developed programs to address the numerous issues regarding HIV/AIDS. The national AIDS hotline (1-800-342AIDS) is a good resource. Table 5.4 provides a summary of the perinatal effects of STIs during pregnancy.

PREVENTING SEXUALLY TRANSMITTED INFECTIONS Education about safer sex practices—and the resulting increase in the use of condoms—can play a vital role in reducing STI rates all over the world. Clearly, knowledge and prevention are the best defenses against STIs. The prevention and control of STIs is based on the following concepts (American College of Obstetricians & Gynecologists [ACOG], 2015; U.S. FDA, 2015): 1. Education and counseling of persons at risk about safer sexual behavior 2. Recommending immunizations that prevent Hepatitis B and HPV preexposure 3. Educating people that latex condoms offer some protection and reduce risk of transmission 4. Identifying asymptomatic infected individuals and symptomatic individuals unlikely to seek diagnosis and treatment 5. Effectively diagnosing and treating infected individuals 6. Evaluating, treating, and counseling sex partners of people who are infected with an STI Nurses play an integral role in identifying and preventing STIs. They have a unique opportunity to educate the public about this serious public health issue by communicating the methods of transmission and symptoms associated with each condition, tracking the updated CDC treatment guidelines, and offering clients strategic preventive measures to reduce the spread of STIs. Nurses have a huge role to play to ensure all women are well educated about STIs by informing them how these infections are transmitted, symptoms, risk factors, potential for adverse effects, screening, and treatment recommendations. Armed with this knowledge, women can make fully informed decisions about accepting screening and adhering to treatment and follow-up advice. It is not easy to discuss STI prevention when globally we are failing at it. Knowledge exists on how to prevent every single route of transmission, but the incidence of STIs continues to climb. Challenges to prevention of STIs include lack of resources and difficulty in changing the behaviors that contribute to their spread. Regardless of the challenging factors involved, nurses must continue to educate and to meet the needs of all women to promote their sexual health.

Successful treatment and prevention of STIs is impossible without education. Successful teaching approaches include giving clear, accurate messages that are age appropriate and culturally sensitive. TABLE 5.4 MATERNAL AND FETAL EFFECTS FROM SEXUALLY TRANSMITTED INFECTIONS

Primary prevention strategies include educating all women, especially adolescents, regarding the risk of early sexual activity, the number of sexual partners, and STIs. Sexual abstinence is ideal but often not practiced; therefore, the use of barrier contraception (condoms) should be encouraged (see Teaching Guidelines 5.1). Secondary prevention involves the need for annual pelvic examinations with Pap smears for all sexually active women, regardless of age. Many women with

STIs are asymptomatic, so regular screening examinations are paramount for early detection. Understanding the relationship between poor socioeconomic conditions and poor patterns of sexual and reproductive self-care is significant in disease prevention and health promotion strategies. Every successful form of prevention requires a change in behavior. The nursing role in teaching and rendering quality health care is invaluable evidence that the key to reducing the spread of STIs is through behavioral change. Nurses working in these specialty areas have a responsibility to educate themselves, their clients, their families, and the community about STIs and to provide compassionate and supportive care to clients. Some strategies nurses can use to prevent the spread of STIs are detailed in Box 5.4.

Behavior Modification Research validates that changing behaviors does result in a decrease in new STI infections, but it must encompass all levels—governments, community organizations, schools, churches, parents, and individuals (WHO, 2015d). Education must address the following: ways to prevent becoming infected; condom promotion; target vulnerable populations such as adolescents, sex workers, men who have sex with men, and people who inject drugs; ways to prevent transmitting infection; symptoms of STIs; and treatment. At this point in the STI epidemic, nurses do not have time to debate the relative merits of prevention versus treatment: both are underused and underfunded, and one leads to the other. But being serious about prevention and focusing on the strategies outlined above will bring about a positive change on everyone’s part.

BOX 5.4 SELECTED NURSING STRATEGIES TO PREVENT THE SPREAD OF SEXUALLY TRANSMITTED INFECTIONS • Provide basic information about STI transmission. • Outline safer sexual behaviors for people at risk for STIs. • Refer clients to appropriate community resources to reduce risk. • Screen asymptomatic persons with STIs. • Identify barriers to STI testing and remove them. • Offer pre-exposure immunizations for vaccine-preventable STIs. • Respond honestly about testing results and options available. • Counsel and treat sexual partners of persons with STIs. • Educate school administrators, parents, and teens about STIs. • Support youth development activities to reduce sexual risk-taking. • Promote the use of barrier methods (condoms, diaphragms) to prevent the spread of STIs. • Assist clients to gain skills in negotiating safer sex. • Discuss reducing the number of sexual partners to reduce risk.

Contraception The spread of STIs could be prevented by access to safe, efficient, appropriate barrier contraceptives. The consistent and correct use of condoms plays an important role in preventing the spread of STIs. Nurses can play an important role in helping women to identify their risk of STIs and to adopt preventive measures through the dual protection that contraceptives offer. Traditionally, family planning and STI services have been separate entities. Family planning services have addressed a woman’s need for contraception without considering her or her partner’s risk of STIs; meanwhile, STI services have been heavily slanted toward men while ignoring their contraceptive needs. Many women are at significant risk for unintended pregnancy and STIs; yet with this separation of services, there is limited evaluation of whether they need dual protection—that is, concurrent protection from STIs and unintended pregnancy. This lack of integration of services represents a missed opportunity to identify many at-risk women and to offer them counseling on dual protection. Nurses can play a key role in influencing clients to initiate and maintain use of the female condom, an underused method for STI and pregnancy prevention (Alexander et al., 2015).

Consider This

I was thinking of my carefree college days, when the most important thing was having an active sorority life and meeting guys. I had been raised by very strict parents and was never allowed to date under their watch. Since I attended an out-of-state college, I figured that my parents’ outdated advice and rules no longer applied. Abruptly, my thoughts of the past were interrupted by the HIV counselor asking about my feelings concerning my positive diagnosis. What was there to say at this point? I had a lot of fun but never dreamed it would haunt me for the rest of my life, which was going to be shortened considerably now. I only wish I could turn back the hands of time and listen to my parents’ advice, which somehow doesn’t seem so outdated now.

Thoughts: All of us have thought back on our lives to better times and wondered how our lives would have changed if we had made better choices or gone down another path. It is a pity that we have only one chance to make good, sound decisions at times. What would you have changed in your life if given a second chance? Can you still make a change for the better now? Nurses can expand their scopes in either setting by discussing dual protection by use of a male or female condom alone or by use of a condom along with a nonbarrier contraceptive. Because barrier methods are not the most effective means of fertility control, they have not been typically recommended as a method alone for dual protection. Unfortunately, the most effective pregnancy prevention methods—sterilization, hormonal methods, and intrauterine systems —do not protect against STIs. Dual-method use protects against STIs and pregnancy. KEY CONCEPTS Avoiding risky sexual behaviors may preserve fertility and prevent chronic conditions later in life. An estimated 65 million people live with an incurable sexually transmitted infection (STI), and another 15 million are infected each year (CDC, 2015a). The most reliable way to avoid transmission of STIs is to abstain from sexual intercourse (i.e., oral, vaginal, or anal sex) or to be in a long-term, mutually monogamous relationship with an uninfected partner. Barrier methods of contraception are recommended because they increase protection from contact with urethral discharge, mucosal secretions, and lesions of the cervix or penis. The high rate of asymptomatic transmission of STIs calls for teaching highrisk women the nature of transmission and how to recognize infections. Nurses should practice good hand hygiene and follow standard precautions to protect themselves and their clients from STIs. Nurses are in an important position to promote the sexual health of all women. Nurses should make their clients and the community aware of the perinatal implications and lifelong sequelae of STIs.

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Virology, 68, 11–15. Thomas, T. L., Yarandi, H. N., Dalmida, S. G., Frados, A., & Klienert, K. (2015). Cross-cultural differences and sexual risk behavior of emerging adults. Journal of Transcultural Nursing, 26(1), 64–72. Tipple, C., & Taylor, G. P. (2015). Syphilis testing, typing, and treatment follow-up: A new era for an old disease. Current Opinion in Infectious Diseases, 28(1), 53–60. U.S. Department of Health and Human Services [USDHHS]. (2010). Healthy people 2020. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx U.S. Food and Drug Administration [FDA]. (2015). Condoms and sexually transmitted diseases. Retrieved fromhttp://www.fda.gov/ForPatients/Illness/HIVAIDS/ucm126372.htm U.S. Preventive Services Task Force [USPSTF]. (2015). USPSTF recommendations. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf12/hepb/hepbfinalresplan.htm Wong, B. (2015). Gonorrhea. eMedicine. Retrieved from http://emedicine.medscape.com/article/218059overview World Health Organization [WHO]. (2015a). Hepatitis B. Retrieved from http://www.who.int/mediacentre/factsheets/fs204/en/ World Health Organization [WHO]. (2015b). HIV/AIDS. Retrieved from http://www.who.int/hiv/en/ World Health Organization [WHO]. (2015c). Adolescents falling through the gaps in HIV services. Retrieved from http://www.who.int/mediacentre/news/releases/2013/hiv-adolescents-20131125/en/ World Health Organization [WHO]. (2015d). Sexually transmitted infections (STIs). Retrieved from http://www.who.int/mediacentre/factsheets/fs110/en/ World Health Organization [WHO]. (2015e). Hepatitus C. Retrieved from http://www.who.int/mediacentre/factsheets/fs164/en/ World Health Organization [WHO]. (2016). Zika virus. Retrieved from http://www.who.int/mediacentre/factsheets/zika/en/

CHAPTER WORKSHEET MULTIPLE CHOICE QUESTIONS 1. The nurse’s primary role related to sexually transmitted infections is: a. Case reporting of partners b. Detection and education c. Sexual counseling d. Diagnosis and treatment

2. A 16-year-old teen comes to the clinic for routine care and is diagnosed with gonorrhea. The teen asks the nurse why she needs treatment for this since she has no symptoms. The nurse should explain that possible complications of lack of treatment could result in: a. Sterility, birth defects, and miscarriage b. The need for future births by cesarean section c. Skin rashes and hearing loss d. Disseminated systemic infections 3. Which of the following contraceptive methods offers protection against sexually transmitted infections (STIs)? a. Oral contraceptives b. Withdrawal c. Latex condom d. Intrauterine contraceptive (IUC) 4. In teaching about human immunodeficiency virus (HIV) transmission, the nurse explains that the virus cannot be transmitted by: a. Shaking hands b. Sharing drug needles c. Sexual intercourse d. Breast-feeding 5. A woman with human papilloma virus (HPV) is likely to present with which nursing assessment finding? a. Profuse, pus-filled vaginal discharge b. Clusters of genital warts c. Single painless ulcer d. Multiple vesicles on genitalia 6. The nurse’s discharge teaching plan for the woman with pelvic inflammatory disease (PID) should reinforce which of the following potentially lifethreatening complications?

a. Involuntary infertility b. Chronic pelvic pain c. Depression d. Ectopic pregnancy 7. To confirm a finding of primary syphilis, the nurse would observe which of the following on the external genitalia? a. A highly variable skin rash b. A yellow–green vaginal discharge c. A nontender, indurated ulcer d. A localized gumma formation

CRITICAL THINKING EXERCISES 1. Sally, age 17, comes to the teen clinic saying that she is in pain and has some “crud” between her legs. The nurse takes her into the examining room and questions her about her symptoms. Sally states she had numerous genital bumps that had been filled with fluid, then ruptured and turned into ulcers with crusts. In addition, she has pain on urination and overall body pain. Sally says she had unprotected sex with several men when she was drunk at a party a few weeks back, but she thought they were “clean.” a. What STI would the nurse suspect? b. The nurse should give immediate consideration to which of Sally’s complaints? c. What should be the goal of the nurse in teaching Sally about STIs?

STUDY ACTIVITIES 1. Go to the CDC web site and select a specific STI of interest. Educate yourself about one specific STI thoroughly and share your expertise with your clinical group. 2. Contact your local health department and request current statistics regarding three STIs. Ask them to compare the current number of cases reported to last year’s report. Has the number of STIs increased or decreased? What may be

some of the reasons for the change in the number of cases reported? 3. Request permission to attend a local STI clinic to shadow a nurse for a few hours. Describe the nurse’s counseling role with clients and what specific information is emphasized to clients. 4. Two common STIs that appear together and are commonly treated together regardless of identification of the secondary one are __________________ and _______________________. 5. Genital warts can be treated with which of the following? Select all that apply. a. Penicillin b. Podophyllin c. Imiquimod d. Cryotherapy e. Antiretroviral therapy f. Acyclovir

BRINGING IT ALL TOGETHER: CASE STUDY Grace, a 25-year-old college student, came back upset from her annual gynecologic appointment at the college health center. The results from her pap smear were “abnormal” and she would need further testing to rule out cervical cancer. She had heard about cervical cancer but did not think it could happen to someone of her age, so she looked for some information on the Internet. What she found surprised and worried her. She learned that each year approximately 13,000 new cases of cervical cancer are found and that over 4,000 women die of the disease. This is twice as many as die of HIV/AIDS. She also learned that 93% of cervical cancers are caused by a virus. Go to

to find questions to consider about this case.

6 Disorders of the Breasts

KEY TERMS benign breast disorder breast augmentation breast cancer breast-conserving surgery breast implants breast self-examination (BSE) carcinoma chemotherapy duct ectasia endocrine therapy fibroadenomas

fibrocystic breast changes mammography mastitis modified radical mastectomy simple mastectomy

Learning Objectives Upon completion of the chapter, you will be able to: 1. Identify the incidence, risk factors, screening methods, and treatment modalities for benign breast conditions. 2. Appraise reasons behind breast augmentation including the potential benefits and risks. 3. Outline preventive strategies for breast cancer through lifestyle changes and health screening. 4. Analyze the incidence, risk factors, treatment modalities, and nursing considerations related to breast cancer. 5. Develop an educational plan to teach BSE to a group of high-risk women. Nancy hasn’t been able to sleep well since she felt the lump in her left breast over a month ago, just after her 60th birthday. She knows she is at high risk because her mother died of breast cancer, but she can’t bring herself to have it checked out.

Words of Wisdom Focus on reducing fear, anxiety, pain, and loneliness in all women diagnosed with a breast disorder.

INTRODUCTION The breasts are modified sweat glands, lying over the pectoralis major muscles of the chest wall. Physiologically, the breast is an organ specialized for milk formation to nourish their offspring. Each breast extends approximately from the second to the sixth rib. The female breasts are closely linked to womanhood in American culture. Women’s breasts act as physical markers for transitions from one stage of life to another, and although the primary function of the breasts is lactation, they are perceived as a symbol of beauty and sexuality. This chapter discusses assessments, screening procedures, and management of specific benign and malignant breast disorders. Nurses play a key role in helping women maintain breast health by providing education and screening. A good working knowledge of early detection techniques, diagnosis, and treatment options is essential.

BENIGN BREAST DISORDERS A benign breast disorder is any noncancerous breast abnormality. Though not life-threatening, benign disorders can cause pain and discomfort, and they account for a large number of visits to primary care providers. Fully understanding benign breast disorders should enable the nurse to appropriately evaluate symptoms, determine which breast lesions require treatment, and identify women who are at increased risk for breast cancer. Depending on the type of benign breast disorder, treatment might or might not be necessary. Although these disorders are benign, the emotional trauma women experience is phenomenal. Fear, anxiety, disbelief, helplessness, and depression are just a few of the reactions that a woman may have when she discovers a lump in her breast. Many women believe that all lumps are cancerous, but actually more than 80% of the lumps discovered are benign and need no treatment (Alexander et al., 2014). Patience, support, and education are essential components of nursing care. The most commonly encountered benign breast disorders in women include fibrocystic changes of the breasts, fibroadenomas, and mastitis. Although these breast disorders are considered benign, fibrocystic changes of the breasts carry a cancer risk, with prolific masses and hyperplastic changes occurring within the breasts. Generally speaking, fibroadenomas and mastitis carry little cancer risk (Seetharam & Rodrigues, 2015). Table 6.1 summarizes benign breast conditions.

Fibrocystic Breast Changes Fibrocystic breast changes, also known as benign breast disease (BBD), represent a variety of changes in the glandular and structural tissues of the breast. Because this condition affects 50% to 60% of all women at some point, it is more accurately defined as a “change” rather than a “disease.” Fibrocystic changes are caused by an overgrowth of fibrous tissues in the connective tissues supporting the breasts. This is frequently accompanied by the presence of fluidfilled cysts, which contribute to the lumpy feeling experienced by women. In contrast to malignant breast lesions, the cysts that develop move freely when palpated and symptoms decline after menopause when levels of estrogen and progesterone drop (Sabel, 2015). Fibrocystic changes do not increase the risk of breast cancer for most women except when the breast biopsy shows “atypia” or abnormal breast cells. The cause for concern for many women with fibrocystic changes is that breast examinations and mammography become more difficult to interpret with multiple cysts present, and early cancerous lesions may occasionally be overlooked (American Cancer Society [ACS], 2015a). TABLE 6.1 SUMMARY OF BENIGN BREAST DISORDERS

Fibrocystic breast changes are most common in women between the ages of 20 and 50. The condition is rare in postmenopausal women not taking hormone

replacement therapy (HRT). According to the ACS (2015a), fibrocystic breast changes affect at least half of all women at some point in their lives and are the most common breast disorder today.

Therapeutic Management Management of the symptoms of fibrocystic breast changes begins with selfcare. For some women, diet and lifestyle changes help to reduce discomfort. Other options include wearing a supportive bra, taking over-the-counter pain relievers, and limiting salt consumption which can cause fluid retention (Files, Allen, & Pruthi, 2015). In severe cases drugs, including bromocriptine, tamoxifen, or danazol, can be used to reduce the influence of estrogen on breast tissue. However, several undesirable side effects, including masculinization, have been documented. Aspiration or surgical removal of breast lumps will reduce pain and swelling by removing the space-occupying mass.

Nursing Assessment Nursing assessment consists of a health history, physical examination, and laboratory and diagnostic tests. HEALTH HISTORY Ask the woman about common clinical manifestations, which include lumpy, tender breasts, particularly during the week before menses. Changes in breast tissue produce pain by nerve irritation from edema in connective tissue and by fibrosis from nerve pinching. The pain is cyclic and frequently dissipates after the onset of menses. The pain is described as a dull, aching feeling of fullness. Masses or nodularities usually appear in both breasts and are often found in the upper outer quadrants. Some women also experience spontaneous clear to yellow nipple discharge when the breast is squeezed or manipulated. PHYSICAL EXAMINATION It is best to examine a woman’s breast a week after menses, when swelling has subsided. The breast exam is performed using the Triple Touch Method in which the health care provider uses the pads of the middle three fingers and makes dime-sized overlapping circles to feel the breast tissue with three levels of pressure: light, medium, and firm (Jarvis, 2015). Observe the breasts for fibrosis,

or thickening of the normal breast tissues, which occurs in the early stages. Cysts form in the later stages and feel like multiple, smooth, well-delineated tiny pebbles or bumpy oatmeal under the skin (Fig. 6.1). On physical examination of the breasts, a few characteristics might be helpful in differentiating a cyst from a cancerous lesion. Cancerous lesions typically are fixed and painless and may cause skin retraction (pulling). Cysts tend to be mobile and tender and do not cause skin retraction in the surrounding tissue. LABORATORY AND DIAGNOSTIC TESTS Mammography can be helpful in distinguishing fibrocystic changes from breast cancer. Ultrasound is a useful adjunct to mammography for breast evaluation because it helps to differentiate a cystic mass from a solid one (Dixon & Macaskill, 2015). Ultrasound produces images of the breasts by sending sound waves through a gel applied to the breasts. Fine-needle aspiration biopsy can also be done to differentiate a solid tumor, cyst, or malignancy. A fine-needle aspiration biopsy uses a thin needle guided by ultrasound to the mass. In a method called stereotactic needle biopsy, a computer maps the exact location of the mass using mammograms taken from two angles, and the map is used to guide the needle.

Nursing Management A nurse caring for a woman with fibrocystic breast changes can teach her about the condition, provide tips for self-care (Teaching Guidelines 6.1), suggest lifestyle changes, and demonstrate how to perform monthly breast selfexamination (BSE) after her menses to monitor the changes. Nursing Care Plan 6.1 presents a plan of care for a woman with fibrocystic breast changes.

Teaching Guidelines 6.1

RELIEVING SYMPTOMS OF FIBROCYSTIC BREAST CHANGES • Wear an extra-supportive bra to prevent undue strain on the ligaments of the breasts to reduce discomfort.

• Take oral contraceptives, as recommended by a health care practitioner, to stabilize the monthly hormonal levels. • Eat a low-fat diet rich in fruits, vegetables, and grains to maintain a healthy nutritional lifestyle and ideal weight. • Apply heat to the breasts to help reduce pain via vasodilation of vessels. • Take diuretics, as recommended by a health care practitioner, to counteract fluid retention and swelling of the breasts. • Reduce salt intake to reduce fluid retention and swelling in the breasts. • Take over-the-counter medications, such as acetylsalicylic acid (Aspirin) or ibuprofen (Motrin, Advil, Nuprin), to reduce inflammation and discomfort. • Use thiamine and vitamin E therapy. This has been found helpful for some women, but research has failed to demonstrate a direct benefit from either therapy. • Take medications as prescribed (e.g., bromocriptine, tamoxifen, or danazol). • Discuss the possibility of aspiration or surgical removal of breast lumps with a health care practitioner. • Avoid caffeinated drinks (coffee, tea, soda) which tend to trigger breast discomfort.

FIGURE 6.1 A. Fibrocystic breast changes. B. Breast cysts. C. This gross study shows that most of the abnormal tissue is fibrous. Cysts are relatively inconspicuous in this example. D. The microscopic study shows dense fibrous tissue containing dilated ducts lined by hyperplastic epithelium. (Images A & B are from The Anatomical Chart Company [2006]. Atlas of Pathophysiology. Springhouse, PA: Springhouse Corporation. Images C & D courtesy of McConnell, Thomas H. [2014]. The Nature of Disease Pathology for the Health Professions, 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins.)

NURSING CARE PLAN 6.1 Overview of the Woman with Fibrocystic Breast Changes Sheree Rollins is a 37-year-old woman who comes to the clinic for her routine checkup. During the examination, she says, “Sometimes my breasts feel so heavy and they ache a lot. I noticed a couple of lumpy areas in my breast last week just before I got my period. Is this normal? Now they feel like they’re almost gone. Should I be worried?” Clinical breast examination reveals two small (pea-sized), mobile, slightly tender nodules in each breast bilaterally. No skin retraction noted. Previous mammogram revealed fibrocystic breast changes. NURSING DIAGNOSIS: Pain related to changes in breast tissue Outcome Identification and Evaluation The client will demonstrate a decrease in breast pain as evidenced by a pain rating of 1 or 2 on a pain rating scale of 0 to 10 and statements that pain is lessened. Interventions: Relieving Pain • Ask client to rate her pain using a numeric pain rating scale to establish a baseline. • Discuss with client any measures used to relieve pain to determine effectiveness of the measures. • Encourage use of a supportive bra to aid in reducing discomfort. • Instruct client in use of over-the-counter analgesics to promote pain relief. • Advise the client to apply warm compresses or allow warm water from the shower to flow over her breasts to promote vasodilation and subsequent pain relief. • Tell client to reduce her intake of salt to reduce risk of fluid retention and swelling leading to increased pain. NURSING DIAGNOSIS: Deficient knowledge related to fibrocystic breast changes and appropriate care measures

Outcome Identification and Evaluation The client will verbalize understanding of condition as evidenced by statements about the cause of breast changes and appropriate choices for lifestyle changes, and demonstration of self-care measures. Interventions: Providing Client Education • Assess client’s knowledge of fibrocystic breast changes to establish a baseline for teaching. • Explain the role of monthly hormonal level changes and describe the signs and symptoms to promote understanding of this condition. • Teach the client how to perform breast self-examination after her menstrual period to monitor for changes. • Encourage client to report any changes promptly to ensure early detection of problems. • Suggest client speak with her primary care provider about the use of oral contraceptives to help stabilize monthly hormonal levels. • Review lifestyle choices, such as eating a low-fat diet rich in fruits, vegetables, and grains, and adhering to screening recommendations to promote health. • Discuss measures for pain relief to minimize discomfort associated with breast changes.

Fibroadenomas Fibroadenomas are common benign solid breast tumors that occur in about 25% of all women and account for up to half of all breast biopsies. They are the most common mass in women aged 15 to 25 years (Seetharam & Rodrigues, 2015). They are considered hyperplastic lesions associated with an aberration of normal development and involution rather than a neoplasm. Fibroadenomas can be stimulated by external estrogen, progesterone, lactation, and pregnancy (Schuiling & Likis, 2016). They are composed of both fibrous and glandular tissue that feels round or oval, firm, rubbery and smooth, and is mobile and may be tender. They are usually unilateral, but may present in both breasts (Alexander et al., 2014). Giant fibroadenomas account for approximately 4% of cases. These masses are frequently larger than 5 cm and occur most often in pregnant or lactating women. These large lesions may regress in size once hormonal stimulation subsides (Janardhan, Venkateshwar, & Rao, 2015). Fibroadenomas are rarely associated with cancer.

FIGURE 6.2 A. Fibroadenoma. (Asset provided by Anatomical Chart Co.) B. Spot compression view of a smoothly marinated mass proven to represent a fibroadenoma. Ultrasonography demonstrated a solid mass.

Therapeutic Management Treatment may include a period of “watchful waiting” because many fibroadenomas stop growing or shrink on their own without any treatment. Other growths may need to be surgically removed if they do not regress or if they remain unchanged. Cryoablation, an alternative to surgery, can also be used to remove a tumor. In this procedure, extremely cold gas is piped into the tumor using ultrasound guidance. The tumor freezes and dies. The current trend is toward a more conservative approach to treatment after careful evaluation and continued monitoring.

Nursing Assessment Ask the woman about clinical manifestations of fibroadenomas. These lumps are felt as firm, rubbery, well-circumscribed, freely mobile nodules that might or might not be tender when palpated. Breast fibroadenomas are usually detected incidentally during clinical or selfexaminations and are usually located in the upper outer quadrant of the breast; more than one may be present (Fig. 6.2). Several other breast lesions have similar characteristics, so every woman with a breast mass should be evaluated to exclude cancer. A clinical breast examination by a health care provider is critical. In addition, diagnostic studies include imaging studies (mammography, ultrasound, or both) and some form of biopsy, most often a fine-needle aspiration, core needle biopsy, or stereotactic needle biopsy. The core needle biopsy removes a small cylinder of tissue from the breast mass, more than the fine-needle aspiration biopsy. If additional tissue needs to be evaluated, the advanced breast biopsy instrument (ABBI) is used. This instrument removes a larger cylinder of tissue for examination by using a rotating circular knife. The ABBI procedure removes more tissue than any of the other methods except a surgical biopsy (ACS, 2015a).

Nursing Management The nurse should urge the client to return for reevaluation in 6 months, perform monthly BSEs, and return annually for a clinical breast examination. Recent

studies suggest that women with high breast density and proliferative benign breast disease are at very high risk for future breast cancer. Women with low breast density are at low risk, regardless of their benign pathologic diagnosis (Slanetz, Freer, & Birdwell, 2015). This is all the more reason for women to have close monitoring over time.

Mastitis Mastitis is an infection or inflammation of the connective tissue in the breast that occurs primarily in lactating or engorged women. The prevalence of it in breastfeeding women may be as high as 33% (Faguy, 2015). Mastitis is divided into lactational or nonlactational types. The usual causative organisms for lactational mastitis are Staphylococcus aureus, Hemophilus influenzae, and hemophilus and streptococcus species, the source of which is the baby’s flora. Lactating mastitis typically occurs in the first two to three weeks of lactation, but can occur at any stage of lactation. One or more of the ducts drain poorly or become blocked, resulting in bacterial growth in the retained milk (Pluchinotta, 2015). The only evidence-based predisposing factor that may lead to mastitis is the development of milk stasis. However, other associated factors include damaged or cracked nipples, especially those colonized with Staphylococcus aureus; irregular or missed feedings; failing to allow the infant to empty one breast completely before moving on to the next breast; poor latch and transfer of milk; illness of mother or infant; oversupply; a tight bra; blocked nipple pore or duct; being primiparous women; and maternal stress and fatigue (Miller & Kennedy, 2015). Nonlactational mastitis can be caused by duct ectasia, which occurs when the milk ducts become congested with secretions and debris, resulting in periductal inflammation. It may be divided into central (periareolar) and peripheral breast lesions. Periareolar infections consist of active inflammation around nondilated subareolar breast ducts—a condition termed periductal mastitis. Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with an underlying condition such as diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis, and trauma (Faguy, 2015). Women with these types of abscesses present with greenish nipple discharge, nipple retraction, and noncyclical pain.

Therapeutic Management Effective milk removal, pain medication, and antibiotic therapy have been the mainstays of treatment. Management of both types of mastitis involves the use of oral antibiotics (usually a penicillinase-resistant penicillin or cephalosporin), warm compresses to the inflamed area of the breast, continued breast-feeding, and acetaminophen (Tylenol) for pain and fever (King et al., 2015).

Nursing Assessment Assess the client’s health history for risk factors for mastitis, which include poor hand hygiene ductal abnormalities, nipple cracks and fissures, lowered maternal defenses due to fatigue, tight clothing, poor support of pendulous breasts, failure to empty the breasts properly while breast-feeding, or missing breast-feedings. The diagnosis of mastitis is made clinically on the basis of a localized, unilateral area of erythema with associated fever. Assess the client for clinical manifestations of mastitis, which include flu-like symptoms of malaise, nausea, headache, leukocytosis, fever, fatigue, and chills. Physical examination of the breasts reveals increased warmth, swollen area of one breast, redness, tenderness, and swelling. The nipple is usually cracked or abraded and the breast is distended with milk (Fig. 6.3). In a lactating woman, severe engorgement can be differentiated from mastitis because engorgement is bilateral with general involvement of the whole breast. Ultrasound scans can be undertaken to differentiate between the types of mastitis or abscesses, but typically the diagnosis is made based on history and examination.

FIGURE 6.3 Mastitis. (From Sweet, R. L., & Gibbs, R. S. [2009]. Infectious diseases of the female genital tract. Philadelphia, PA: Lippincott Williams & Wilkins.)

Nursing Management Teach the woman about the etiology of mastitis and encourage her to continue to breast-feed, emphasizing that it is safe for her infant to do so. Stress to all breastfeeding mothers to check for medication safety before taking it. Drugs administered to mothers can accumulate in the bodies of their infants and can

alter infant’s bowel flora, causing diarrhea. Mothers should be warned about this to reduce their anxiety. Once it has been declared safe to do so, the nurse should urge them to take the medication as prescribed until completed. Continued emptying of the breast or pumping improves the outcome, decreases the duration of symptoms, and decreases the incidence of breast abscess. Thus, continued breast-feeding is recommended in the presence of mastitis (King et al., 2015). Although 80% of breast biopsy results prove to be benign, increased surveillance is necessary because of the risk of cancer development. The recommended follow-up schedule is imaging (mammography or ultrasound) and a clinical breast exam by a surgeon at 6, 12, and 24 months after a benign breast biopsy finding (Tharpe, Farley, & Jordan, 2016). Instructions for the woman with mastitis are detailed in Teaching Guidelines 6.2.

Teaching Guidelines 6.2

CARING FOR MASTITIS • Take medications as prescribed to reduce inflammation and infection. • Continue breast-feeding, as tolerated to keep the milk flowing. • Begin feeding on most affected breast to allow it to be emptied first. • Massage the breasts before and during breast-feeding to encourage milk extraction. • Wear a supportive bra 24 hours a day to support the breasts for comfort. • Increase fluid intake to stay hydrated. • Gentle massage toward nipple several times daily. • Vary the infants breast-feeding position – cradle, side-lying, football and belly to belly • Make sure infant is positioned correctly on the nipple to prevent discomfort. • Practice good hand hygiene techniques to reduce risk of bacterial transfer. • Apply warm compresses to the affected breast or take a warm shower before breast-feeding. • Frequently change positions while nursing to improve milk flow.

• Get adequate rest and nutrition to support or improve the immune system. • Instruct to contact their health care provider if fever returns, chills, or worsening symptoms. Adapted from American Cancer Society [ACS]. (2015a). Non-cancerous breast conditions. Retrieved from http://www.cancer.org/healthy/findcancerearly/womenshealth/non-cancerousbreastconditions/noncancerous-breast-conditions-intro; King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery (5th ed.), Berlington, MA: Jones & Bartlett Learning; and Tharpe, N. L., Farley, C. L., & Jordan, R. G. (2016). Clinical practice guidelines for midwifery & women’s health. (4th ed.), Burlington, MA: Jones & Bartlett Learning.

MALIGNANT BREAST DISORDER Breast cancer is a neoplastic disease in which normal body cells are transformed into malignant ones (National Cancer Institute ([NCI], 2015a). It is the most common cancer in women and the second leading cause of cancer deaths (lung cancer is first) among American women. Breast cancer accounts for one of every three cancers diagnosed in the United States (ACS, 2015a). A new case is discovered every 2 minutes. It is estimated that 1 out of every 8 women will develop the disease at some time during her life, and the mortality rate of those with breast cancer is 1 in 36 (NCI, 2015a). Over 200,000 cases of invasive breast cancer are diagnosed in the United States each year (ACS, 2015a). Breast cancer can also affect men, but only 1% of all individuals diagnosed with breast cancer annually are men. About 2000 men are diagnosed with breast cancer annually, with about a 1 in 4 mortality rate (Khan, Allerton, & Petitt, 2015). Because men are not routinely screened for breast cancer, the diagnosis is often delayed. The most common clinical manifestation of male breast cancer is a painless, firm, subareolar breast mass. Any suspicious breast mass in a male should undergo diagnostic biopsy. If a malignancy is diagnosed, typical treatment is mastectomy with assessment of the axillary nodes.

Consider This

It was pouring down rain and I was driving alone along dark wet streets to my 8 AM appointment for a breast ultrasound. I recently had my annual mammogram and the radiologist thought he saw something suspicious on my right breast. I was on my way to confirm or refute his suspicions, and I couldn’t keep focused on the road ahead. For the past few days I had been a basket case, fearing the worst. I was playing in my mind, what I would do if…? What changes would I make in my life and how would I react when told? I have been through such personal turmoil since that doctor announced he wanted “more tests.”

Thoughts: This woman is worrying and is emotionally devastated before she even has a conclusive diagnosis. Is this a typical reaction to a breast disorder? Why do women fear the worst? Many women use denial to mask their feelings and hope against hope the doctor made a mistake or misread their mammogram. How would you react if you or your sister, girlfriend, or mother were confronted with a breast disorder? The cause of breast cancer, while not well understood, is thought to be a complex interaction between environmental, genetic, and hormonal factors. Breast cancer is a progressive rather than a systemic disease, meaning that most cancers grow from small size with low metastatic potential to larger size and greater metastatic potential. Tumor stage, size, and lymph node involvement are major predictors of metastatic potential (Arora et al., 2015).

Pathophysiology Cancer is not just one disease, but rather a group of diseases that result from unregulated cell growth. Without regulation, cells divide and grow uncontrollably until they eventually form a tumor. Extensive research has determined that all cancer is the result of changes in DNA or chromosome structure that cause the mutation of specific genes. Most genetic mutations that cause cancer are acquired sporadically, which means they occur by chance and are not necessarily due to inherited mutations (Shannon & Chittenden, 2015). Cancer development is thought to be clonal in nature, which means that each cell is derived from another cell. If one cell develops a mutation, any daughter cell derived from that cell will have that same mutation, and this process continues until a malignant tumor forms. Breast cancer starts in the epithelial cells that line the mammary ducts within the breast. The growth rate depends on hormonal influences, mainly estrogen and progesterone. The two major categories of breast cancer are noninvasive and invasive. Noninvasive, or in situ, breast cancers are those that have not extended beyond their duct, lobule, or point of origin into the surrounding breast tissue. Conversely, invasive (infiltrating) breast cancers have extended into the surrounding breast tissue, with the potential to metastasize. Many researchers believe that most invasive cancers probably originate as noninvasive cancers (Cuzick & Thorat, 2015). Breast cancer is considered to be a highly variable disease. While the process of metastasis is a complex and poorly understood phenomenon, there is evidence to suggest that new vascularization of the tumor plays an important role in the biologic aggressiveness of breast cancer (Toi et al., 2015). Breast cancer metastasizes widely and to almost all organs of the body, but primarily to the bone, lungs, lymph nodes, liver, and brain. The first sites of metastases are usually local or regional, involving the chest wall or axillary supraclavicular lymph nodes or bone (ACS, 2015a).

Invasive Ductal Carcinoma By far the most common breast cancer is invasive ductal carcinoma, which represents 85% of all cases (ACS, 2015c). Carcinoma is a malignant tumor that occurs in epithelial tissue; it tends to infiltrate and give rise to metastases. The

incidence of this cancer peaks in the sixth decade of life (>60 years old). It spreads rapidly to axillary and other lymph nodes, even while small. Infiltrating ductal carcinoma may take various histologic forms—well differentiated and slow growing, poorly differentiated and infiltrating, or highly malignant and undifferentiated with numerous metastases. This common type of breast cancer starts in the ducts, breaks through the duct wall, and invades the fatty breast tissue. This type of cancer accounts for 75% of all breast cancers (Stopeck, Chalasani, & Thompson, 2015).

Invasive Lobular Carcinoma Invasive lobular carcinomas, which originate in the terminal lobular units of breast ducts, account for 10% of all cases of breast cancer. The peak incidence is in women aged 40 to 50 years old. It presents as an area of ill-defined thickening rather than a palpable mass. The tumor is frequently located in the upper outer quadrant of the breast, and by the time it is discovered the prognosis is usually poor (Selvi, 2015).

Other Invasive Carcinomas Other invasive types of cancer include tubular carcinoma (29%), which is fairly uncommon and typically occurs in women aged 55 and older. Colloid carcinoma (2% to 4%) occurs in women 60 to 70 years of age and is characterized by the presence of large pools of mucus interspersed with small islands of tumor cells. Medullary carcinoma accounts for 5% to 7% of malignant breast tumors; it occurs frequently in younger women (50 years old) • Genetic mutations (BRCA1 and BRCA2 genes) • Personal history of ovarian or colon cancer • Increased breast density increases the risk three- to fivefold • Family history of breast cancer • Personal history of breast cancer (three- to fourfold increase in risk for recurrence) • Race/Ethnicity (higher in White women, but African-American women are more likely to die of it) • Previous abnormal breast biopsy (atypical hyperplasia) • Exposure to chest radiation (radiation damages DNA) • Previous breast radiation (12 times normal risk) • Early menarche (55 years old), which represents increased estrogen exposure over the lifetime • Modifiable risk factors related to lifestyle choices (ACS, 2015b) include: • Not having children at all or not having children until after age 30—this increases the risk of breast cancer by not reducing the number of menstrual cycles • Postmenopausal use of estrogens and progestins—the Women’s Health Initiative study (2002) reported increased risks with long-term (>5 years) use of HRT • Failing to breast-feed for up to a year after pregnancy—increases the risk of breast cancer because it does not reduce the total number of lifetime menstrual cycles • Alcohol consumption—boosts the level of estrogen in the bloodstream • Smoking—exposure to carcinogenic agents found in cigarettes • Obesity and consumption of high-fat diet—fat cells produce and store estrogen, so more fat cells create higher estrogen levels • Sedentary lifestyle and lack of physical exercise—increases body fat, which

houses estrogen TABLE 6.3 ESTIMATED RISK OF BREAST CANCER AT SPECIFIC AGES

Breast cancer incidence rates are higher in non-Hispanic White women compared with African-American women for most age groups. However, African-American women have a higher incidence rate before 40 years of age and are more likely to die from breast cancer at every age (ACS, 2015b). Some of that gap is because of social factors such as poverty and restricted access to health care. Some studies have also found genetic differences in the type of breast cancer that develops in African-American and White women. Little is known, however, about whether other risk factors have a different impact in women of different races. A new study’s findings suggest that the risk factors are similar in both races (ACS, 2015b). The presence of risk factors, especially several of them, calls for careful ongoing monitoring and evaluation to promote early detection. Even though risk factors are important considerations, many women with newly diagnosed breast cancer have no known risk factors. Although routine mammography and selfexamination are prudent for high-risk women, these precautions may become lifesavers for early detection of cancerous lesions. Consuming a low-fat diet with plenty of fruits, vegetables, legumes, and whole grains can provide all the vitamins and nutrients our bodies need and has been shown to significantly reduce the risk of developing many types of cancer. A plant-based diet can also reduce cancer recurrence: high-fiber, low-fat diets rich in fruits and vegetables, avoiding sugared beverages and calorie dense

foods, and processed meats reduces breast cancer recurrence (Catsburg et al., 2015). They studied the effectiveness of a high-vegetable, low-fat diet, aimed at markedly raising circulating carotenoid concentrations from food sources, in reducing additional breast cancer events and early death in women with earlystage invasive breast cancer. It is a prescription for cancer prevention that has only positive side effects—lower cholesterol, weight loss, and a lower risk of heart disease. Adherence to a plant-based diet that limits red meat intake may be associated with reduced risk of breast cancer, particularly in postmenopausal women (Catsburg et al., 2015). Screening for breast cancer begins with a routine history and physical exam. Nurses should take every opportunity to educate and emphasize the goal of breast cancer screening: early detection reduces mortality. Screening also includes a BSE, clinical breast exam, and mammography.

Diagnosis Many studies can be performed to make an accurate diagnosis of a malignant breast lump. Diagnostic tests include: • Diagnostic mammography or digital mammography • Magnetic resonance mammography (MRM) • Fine-needle aspiration • Stereotactic needle-guided biopsy • Sentinel lymph node biopsy • Hormone receptor status • Infrared thermal imaging • DNA ploidy status • Cell proliferative indices • HER-2/neu genetic marker (Han et al., 2015)

Mammography Mammography has become an accepted screening procedure that is sanctioned by most cancer organizations and is paid for annually by most health insurance agencies. Mammography serves a twofold purpose: to screen and to diagnose. Mammography involves taking x-ray pictures of a bare breast while it is compressed between two plastic plates. This procedure is a screening tool used to identify and characterize a breast mass and to detect an early malignancy. It remains the gold standard screening method for women at average risk for breast cancer. It is relatively inexpensive, requires only a low dose of radiation, and reliably identifies malignant tumors, especially those that are too small to feel. It can also be used to investigate breast lumps and other symptoms. A screening mammogram typically consists of four views, two per breast (Fig. 6.5). It can detect lesions as small as 0.5 cm (the average size of a tumor detected by a woman practicing occasional BSE is approximately 2.5 cm) (Rifkin & Lazris, 2015). A diagnostic mammogram is performed when a woman has suspicious clinical findings on a breast examination or an abnormality has been found on a screening mammogram. A diagnostic mammogram uses additional views of the

affected breast as well as magnification views. Diagnostic mammography provides the radiologist with additional detail to render a more specific diagnosis. Currently, digital mammography is being used to diagnose breast lesions.

FIGURE 6.5 Mammography. A. A top-to-bottom view of the breast. B. A side view of the breast.

Most women find the 10-minute mammography procedure uncomfortable but not painful. Teaching Guidelines 6.3 offers tips for a client to follow before she undergoes this procedure.

Teaching Guidelines 6.3

PREPARING FOR A SCREENING MAMMOGRAM • Schedule the procedure just after menses, when breasts are less tender. • Do not use deodorant or powder on the day of the procedure, because they can appear on the x-ray film as calcium spots. • Acetaminophen (Tylenol) or acetylsalicylic acid (aspirin) can relieve any discomfort after the procedure. • Remove all jewelry from around your neck, because the metal can cause distortions on the film image. • Select a facility that is accredited by the American College of Radiology to ensure appropriate credentialed staff. The U.S. Preventive Services Task Force (USPSTF) changed its recommendations for breast cancer screening in 2009, resulting in considerable controversy. The USPSTF now recommends biennial screening mammography for women aged 50 to 74 years. Previously, women 40 years and older were advised to start screening mammography. They stated that the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take client context into account, including the client’s values regarding specific benefits and harms. In addition, the USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Finally, the USPSTF recommended against teaching BSE because scientific evidence does not support this practice as a valid screening method for women since its sensitivity ranges from 12% to 41%, lower than that of the clinical breast exam done by a health care provider and mammography, and it is agedependent. The USPSTF is currently updating their breast cancer screening recommendation guidelines and may return to every 1 to 2 years for women age 40 or older for diagnostic mammograms (USPSTF, 2015). The American Cancer Society (ACS) has different guidelines for women with no symptoms or family history of breast cancer than the USPSTF. They still recommend annual mammograms and clinical breast exams for women starting at age 40 and do not recommend stopping them at any age. They also recommend a clinical breast exam about every three years for women in their 20s and 30s and every year for women >40. BSE is an option for women starting in their 20s (ACS, 2015d).

The American Congress of Obstetricians and Gynecologists (ACOG) recommends that mammography screening be offered annually to women beginning at age 40. Previous ACOG guidelines recommended mammograms every 1 to 2 years starting at age 40 and annually beginning at age 50. ACOG continues to recommend annual clinical breast exams (CBEs) for women aged 40 and older, and every 1 to 3 years for women aged 20 to 39. Additionally, it encourages breast self-awareness for women ages 20 and older (ACOG, 2015). This conflicting information can be confusing to women trying to make decisions about breast cancer screening. Nurses can present the latest evidencebased research to help women make informed decisions based on their age, overall health status, and family history of cancer. (See Table 6.4 for a helpful outline.) There really isn’t any clear direction given to women by the authoritative agencies; they in essence leave the decision up to the woman and her health care provider. The associated risk is delay in detecting a breast lesion early when it could be treated and her life saved.

Magnetic Resonance Mammography MRM is a relatively new procedure that might allow for earlier detection because it can detect smaller lesions and provide finer detail. MRM is a highly accurate (>90% sensitivity for invasive carcinoma) but costly tool. Contrast infusion is used to evaluate the rate at which the dye initially enters the breast tissue. The basis of the high sensitivity of MRM is the tumor angiogenesis (vessel growth) that accompanies a majority of breast cancers, even early ones. Malignant lesions tend to exhibit increased enhancement within the first 2 minutes (Bhatti et al. 2015). Currently MRM is used as a complement to mammography and CBE because it is expensive, but recent research findings report that it is more accurate than mammography for size assessment of breast lesions (Poulos, 2015). TABLE 6.4 SCREENING RECOMMENDATIONS FROM USPSTF, ACS, AND ACOG

Fine-Needle Aspiration Biopsy or Core Biopsy Fine-needle aspiration biopsy is done to identify a solid tumor, cyst, or malignancy. It is a simple office procedure that can be performed with or without anesthesia. A small (23 to 27-gauge) needle connected to a 10-mL or larger syringe is inserted into the breast mass and suction is applied to withdraw the contents. The aspirate is then sent to the cytology laboratory to be evaluated for abnormal cells. A core needle biopsy is much like a fine needle biopsy except that a larger needle is used to withdraw small cylinders or cores of tissue from the abnormal area of the breast. It takes longer than the fine needle biopsy, but more tissue is sampled to be tested.

Stereotactic Needle-Guided Biopsy This diagnostic tool is used to target and identify mammographically detected nonpalpable lesions in the breast. This procedure is less expensive than an excisional biopsy. The procedure takes place in a specially equipped room and generally takes about an hour. Women are required to lie prone and must be able to remain still for approximately 20 minutes while the biopsy is taken. When proper placement of the breast mass is confirmed by digital mammograms, the breast is locally anesthetized and a spring-loaded biopsy gun is used to obtain

two or three core biopsy tissue samples. After the procedure is finished, the biopsy area is cleaned and a sterile dressing is applied.

Sentinel Lymph Node Biopsy The status of the axillary lymph nodes is an important prognostic indicator in early-stage breast cancer. The presence or absence of malignant cells in lymph nodes is highly significant: the more lymph nodes involved and the more aggressive the cancer, the more powerful chemotherapy will have to be, both in terms of the toxicity of drugs and the duration of treatment (Tsujimoto, 2015). With a sentinel lymph node biopsy, the clinician can determine whether breast cancer has spread to the axillary lymph nodes without having to do a traditional axillary lymph node dissection. Experience has shown that the lymph ducts of the breast typically drain to one lymph node first before draining through the rest of the lymph nodes under the arm. The first lymph node is called the sentinel lymph node. This procedure can be performed under local anesthesia. A radioactive blue dye is injected 2 hours before the biopsy to identify the afferent sentinel lymph node. The surgeon usually removes one to three nodes and sends them to the pathologist to determine whether cancer cells are present. The sentinel lymph node biopsy is usually performed before a lumpectomy to make sure the cancer has not spread. Removing only the sentinel lymph node can allow women with breast cancer to avoid many of the side effects (lymphedema) associated with a traditional axillary lymph node dissection. This procedure is associated with less morbidity compared to the axillary lymph node dissection, which results in more accurate staging, better axillary tumor control and improved survival. It is considered a standard of care for initial evaluation of metastatic spread to the axillary lymph node chain (Chatterjee, Serniak, & Czerniecki, 2015).

Hormone Receptor Status Normal breast epithelium has hormone receptors and responds specifically to the stimulatory effects of estrogen and progesterone. Most breast cancers retain estrogen receptors, and for those tumors estrogen will retain proliferative control over the malignant cells. It is therefore, useful to know the hormone receptor status of the cancer to predict which women will respond to hormone manipulation. Hormone receptor status reveals whether the tumor is stimulated to grow by estrogen and progesterone. Postmenopausal women tend to be ER+;

premenopausal women tend to be ER− (Kalinsky et al., 2015). To determine hormone receptor status, a sample of breast cancer tissue obtained during a biopsy or a tumor removed surgically during a lumpectomy or mastectomy is examined by a cytologist.

Therapeutic Management Women diagnosed with breast cancer have many treatments available to them. Generally, treatments fall into two categories: local and systemic. Local treatments are surgery and radiation therapy. Effective systemic treatments include chemotherapy, hormonal therapy, and immunotherapy (Evidence-Based Practice 6.1). Treatment plans are based on multiple factors, with the primary factors being whether the cancer is invasive or noninvasive, the tumor’s size and grade, the number of cancerous axillary lymph nodes, the hormone receptor status, and the ability to obtain clear surgical margins (ACS, 2015e). A combination of surgical options and adjunctive therapy is often recommended. Another consideration in making decisions about a treatment plan is genetic testing for BRCA1 and BRCA2 genetic mutations. This genetic testing became available in 1995 and can pinpoint women who have a significantly increased risk for breast, ovarian cancer, and contralateral breast cancer: individuals with BRCA1 and BRCA2 mutations have a 75% lifetime risk of breast cancer and a 30% lifetime risk of ovarian cancer. Most cases of breast and ovarian cancer are sporadic in nature, but approximately 10% of breast and ovarian cancers are thought to result from genetic inheritance (Li et al., 2015). DNA (from a blood or saliva sample) is needed for mutation testing. The sample is sent to a laboratory for analysis. It usually takes about a month to get the results back. Testing positive for a BRCA1 or BRCA2 mutation can significantly alter health care decisions. In some cases, before genetic testing was available, lumpectomy with radiation, or mastectomy was the treatment most often recommended. However, if the woman is found to have a BRCA1 mutation, she is most likely to be offered the option of bilateral prophylactic mastectomy and possible bilateral oophorectomy. A recent study found that current evidence does not support worse breast cancer survival of BRCA1/2 mutation carriers in the adjuvant setting; differences if any are likely to be small when compared to non BRCA 1/2 mutation carriers (van den Broek et al., 2015). Discovery of mutations in the breast and ovarian cancer susceptibility genes BRCA1 and BRCA2 can have emotional consequences for both the tested individual and his or her relatives.

EVIDENCE-BASED PRACTICE 6.1 COMBINATION (SEVERAL DRUGS AT A TIME) VERSUS SEQUENTIAL CHEMOTHERAPY (SAME DRUG GIVEN ONE AFTER THE OTHER) FOR METASTATIC BREAST CANCER

STUDY Combination chemotherapy can cause greater tumor cell kill if the drug dose is not compromised, while sequential single agent chemotherapy may allow for greater dose intensity and treatment time, potentially meaning greater benefit from each single agent. In addition, sequentially using single agents might cause less toxicity and impairment of quality of life, but it is not known whether this might compromise survival time. The purpose of this study was to assess the effect of combination chemotherapy compared to the same drugs given sequentially in women with metastatic breast cancer.

Findings Randomized controlled trials of combination chemotherapy compared to the same drugs used sequentially in women with metastatic breast cancer in the first-, second-, or third-line setting were selected. Twelve trials reporting on nine treatment comparisons (2317 patients randomized) were identified. The findings concluded that sequential single agent chemotherapy has a positive effect on progression-free survival, whereas combination chemotherapy has a higher response rate and a higher risk of febrile neutropenia in metastatic breast cancer. There was no difference in overall survival time between these treatment strategies, but when drugs were given one at a time, there was more time before the tumors grew back again. However, combination chemotherapy caused tumors to shrink more. Generally this study supports the recommendations by international guidelines to use sequential monotherapy unless there is rapid disease progression.

Nursing Implications Although not entirely conclusive in its findings, nurses need to be aware of this study’s findings to be able to counsel women when both therapies are being considered. This study suggests that accurate information about both therapies is needed for all women with metastatic breast cancer, for them to make an informed decision. Nurses need to remember that metastatic breast cancer is not currently curable, but can be effectively treated with chemotherapy. Average survival is about two years, but many women live much longer. The type of therapy chosen should take into consideration optimizing survival, minimizing side effects, and quality of life. Adapted from Dear, R. F., McGeechan, K, Jenkins, M. C., Barratt, A., Tattersall, M. H. N, & Wilcken, N. (2015). Combination versus sequential single agent chemotherapy for metastatic breast cancer. Cochrane Database of Systematic Reviews, 2013 (3), Art. No.: CD008792. DOI: 10.1002/14651858.CD008792.pub2.

Severe psychological distress can occur as a result of genetic testing. Their distress relates to family cancer history, relationships, coping strategies, communication patterns, and mutation status (Wevers et al., 2015). Nurses might find it useful to explore these issues in order to prepare clients before BRCA1/BRCA2 testing and to support them through shifts in family dynamics after disclosure of results. Also, many women perceive their breasts as intrinsic to their femininity, self-esteem, and sexuality, and the risk of losing a breast can provoke extreme anxiety (Alexander et al., 2014). Nurses need to address the physical, emotional, and spiritual needs of the women they care for, as well as their families, since this mutation is inherited in an autosomal dominant fashion. Nurses should identify the woman’s personal coping style which has an impact on her likelihood of experiencing distress after her diagnosis. Women who are emotionally expressive and/or have a “fighting spirit” usually experience lower levels of emotional distress. Based on Mendelian genetics, women with BRCA1 and BRCA2 mutations have a 5- to 20-fold increased risk of developing breast and ovarian cancer (Caple & Schub, 2015).

Surgical Options

Generally, the first treatment option for a woman diagnosed with breast cancer is surgery. A few women with tumors larger than 5 cm or inflammatory breast cancer may undergo neoadjuvant chemotherapy or radiotherapy to shrink the tumor before surgical removal is attempted (Debled et al., 2015). The surgical options depend on the type and extent of cancer. The choices are typically either breast-conserving surgery (lumpectomy with radiation) or mastectomy with or without reconstruction. The overall survival rate with lumpectomy and radiation is about the same as that with modified radical mastectomy (ACS, 2015f). Research has shown that the survival rates in women who have had mastectomies versus those who have undergone breast-conserving surgery followed by radiation are the same. However, lumpectomy may not be an option for some women, including those: • Who have two or more cancer sites that cannot be removed through one incision • Whose surgery will not result in a clean margin of tissue • Who have active connective tissue conditions (lupus or scleroderma) that make body tissues especially sensitive to the side effects of radiation • Who have had previous radiation to the affected breast • Whose tumors are larger than 5 cm (2 inches) (National Comprehensive Cancer Network [NCCN], 2015). These decisions are made jointly between the woman and her surgeon. If mastectomy is chosen, because of either tumor characteristics or client preference, then discussion needs to include breast reconstruction and regional lymph node biopsy versus sentinel lymph node biopsy. The mastectomy techniques are a simple mastectomy with sentinel node biopsy or a radical mastectomy with regional node biopsy. Removal of numerous lymph nodes places the client at high risk for lymphedema. BREAST-CONSERVING SURGERY Breast-conserving surgery, the least invasive procedure, is the wide local excision (or lumpectomy) of the tumor along with a 1-cm margin of normal tissue. A lumpectomy is often used for early-stage localized tumors. The goal of breast-conserving surgery is to remove the suspicious mass along with tissue free of malignant cells to prevent recurrence. The results are less drastic and emotionally less scarring than having a mastectomy to the woman. Women

undergoing breast-conserving therapy receive radiation after lumpectomy with the goal of eradicating residual microscopic cancer cells to limit locoregional recurrence. In women who do not require adjuvant chemotherapy, radiation therapy typically begins 2 to 4 weeks after surgery to allow healing of the lumpectomy incision site. Radiation is administered to the entire breast at daily doses over a period of several weeks (Corradini et al., 2015). A sentinel lymph node biopsy may also be performed since the lymph nodes draining the breast are located primarily in the axilla. Theoretically, if breast cancer is to metastasize to other parts of the body, it will probably do so via the lymphatic system. If malignant cells are found in the nodes, more aggressive systemic treatment may be needed. MASTECTOMY A simple mastectomy is the removal of all breast tissue, the nipple, and the areola. The axillary nodes and pectoral muscles are spared. This procedure would be used for a large tumor or multiple tumors that have not metastasized to adjacent structures or the lymph system. A modified radical mastectomy is another surgical option; conducive to breast reconstruction and results in greater mobility and less lymphedema (Alexander et al., 2014). This procedure involves removal of breast tissue, and a few positive axillary nodes. Breast-conserving surgeries do not increase the future risk of death from recurrent disease when compared mastectomy (Schuiling & Likis 2016). In conjunction with the mastectomy, lymph node surgery (removal of underarm nodes) may need to be done to reduce the risk of distant metastasis and improve a woman’s chance of long-term survival. For women with a positive sentinel node biopsy, 10 to 20 underarm lymph nodes may need to be removed. Complications associated with axillary lymph node surgery include nerve damage during surgery, causing temporary numbness down the upper aspect of the arm; seroma formation (fluid build-up) followed by wound infection; restrictions in arm mobility (some women need physiotherapy); and lymphedema (swelling related to the lymph glands). In many women lymphedema can be avoided by: • Avoiding using the affected arm for drawing blood, inserting intravenous lines, or measuring blood pressure (can cause trauma and possible infection) • Seeking medical care immediately if the affected arm swells

• Wearing gloves when engaging in activities such as gardening that might cause injury • Wearing a well-fitted compression sleeve to promote drainage return Women having mastectomies must decide whether to have further surgery to reconstruct the breast. If the woman decides to have reconstructive surgery, it ideally is performed immediately after the mastectomy. The woman must also determine whether she wants the surgeon to use saline implants or natural tissue from her abdomen (TRAM flap method) or back (LAT flap method). If reconstructive surgery is desired, the ultimate decision regarding the method will be determined by the woman’s anatomy (e.g., is there sufficient fat and muscle to permit natural reconstruction?) and her overall health status. Both procedures require a prolonged recovery period. Some women opt for no reconstruction, and many of them choose to wear breast prostheses. Some prostheses are worn in the bra cup and others fit against the skin or into special pockets created into clothing. Whether to have reconstructive surgery is an individual and very complex decision. Each woman must be presented with all of the options and then allowed to decide. The nurse can play an important role here by presenting the facts to the woman so that she can make an intelligent decision to meet her unique situation. Breast reconstruction surgery can help restore the look and feel of the breast after a mastectomy. Performed by a plastic surgeon, breast reconstruction can be done immediately after the mastectomy or at a later date. Breast reconstruction can be done with breast implants (filled with saline or silicone); natural tissue flaps (using skin fat and muscle from your own body); or a combination of both. Side effects or complications include risk of rupture, hardening of the tissues around the implant, infection, and pain. Nurses need to educate the woman about these potential problems and make sure they understand before consenting to breast reconstruction. See Figure 6.6 for examples of pre- and postmastectomy and reconstruction.

FIGURE 6.6 Before and after photos of postmastectomy and reconstruction.

BREAST AUGMENTATION Breast augmentation is a common surgical procedure with women undergoing it with implants for a variety of reasons ranging from aesthetic to reconstructive surgery following a mastectomy. Saline-filled or silicone-filled implants are used in cosmetic enhancement and reconstructive surgeries. The exact anatomical placement of breast implants can vary, but the location typically is subglandular (over the pectoral muscle) or subpectoral (under the muscle). Breast implants are not lifetime devices, but most are guaranteed for approximately 10 years in case of rupture. Breast augmentation with implants is not without risks. Potential complications include capsular contracture, rippling, implant rupture, infection, or hematoma. Capsular contraction occurs when scar tissue forms, contracts, and hardens around the implant. Rippling most often occurs when wrinkles form in the implant or as a complication of contracture (Mugea, 2015). Breast examination in women with reconstructive surgery is done exactly the same way as for natural breasts. Breasts with implants in place usually feel firmer than normal breast tissue on palpation due to the formation of a fibrotic band or capsule around the implant. If implants are used, press firmly inward at

the edges of the implant to feel the ribs beneath.

Adjunctive Therapy Adjunctive therapy is supportive or additional therapy that is recommended after surgery. Adjunctive therapies include local therapy such as radiation therapy and systemic therapies using chemotherapy, hormonal therapy, and immunotherapy. RADIATION THERAPY Radiation therapy (also called radiotherapy) uses high-energy rays to destroy cancer cells that might have been left behind in the breast, chest wall, or underarm area after a tumor has been removed surgically. Usually serial radiation doses are given 5 days a week to the tumor site for 6 to 8 weeks postoperatively. Each treatment takes only a few minutes, but the dose is cumulative. Women undergoing breast-conserving therapy receive radiation to the entire breast after lumpectomy with the goal of eradicating residual microscopic cancer cells to reduce the chance of recurrence (Chu et al., 2015). Side Effects. Side effects of traditional radiation therapy include inflammation, local edema, anorexia, swelling, and heaviness in the breast; sunburn-like skin changes in the treated area; and fatigue. Changes to the breast tissue and skin usually resolve in about a year in most women (Lara et al., 2015). This type of therapy can be given several ways: external beam radiation, which delivers a carefully focused dose of radiation from a machine outside the body, or internal radiation, in which tiny pellets that contain radioactive material are placed into the tumor. Several advances have taken place in the field of radiation oncology for the treatment of women with early-stage breast cancer that assist in reducing the side effects. The treatment position for external radiation has changed from supine to prone, with the arm on the affected side raised above the head, so that the treated breast hangs dependently through the opening of the treatment board. Treatment in the prone position improves dose distribution within the breast and allows for a decrease in the dose delivered to the heart, lung, chest wall, and other breast (NCCN, 2015). High-dose brachytherapy is another advance that is an alternative to traditional radiation treatment. A balloon catheter is used to insert radioactive seeds into the breast after the tumor has been removed surgically. The seeds

deliver a concentrated dose directly to the operative site; this is important because most cancer recurrences in the breast occur at or near the lumpectomy site (Chang et al., 2015). This allows a high dose of radiation to be delivered to a small target volume with a minimal dose to the surrounding normal tissue. This procedure takes 4 to 5 days as opposed to the 4 to 6 weeks that traditional radiation therapy takes; it also eliminates the need to delay radiation therapy to allow for wound healing. Brachytherapy is now used as a primary radiation treatment after breast-conserving surgery in selected women as an alternative to whole breast irradiation (Guinot et al., 2015). Side effects of brachytherapy include redness or discharge around catheters, fever, and infection. Daily cleansing of the catheter insertion site with a mild soap and application of an antibiotic ointment will minimize the risk of infection. Intensity-modulated radiation therapy (IMRT) offers still another new approach to the delivery of treatment to reduce the dose within the target area while sparing surrounding normal structures. A computed tomography scan is used to create a three-dimensional model of the breast. Based on this model, a series of intensity-modulated beams is produced to the desired dose distribution to reduce radiation exposure to underlying structures. Acute toxicity is thus minimized (Muralidhar, Soubhagya, & Ahmed, 2015). Research is ongoing to evaluate the impact of all of these advances in radiation therapy. CHEMOTHERAPY Chemotherapy refers to the use of drugs that are toxic to all cells and interfere with a cell’s ability to reproduce. They are particularly effective against malignant cells but affect all rapidly dividing cells, especially those of the skin, the hair follicles, the mouth, the gastrointestinal tract, and the bone marrow. Breast cancer is a systemic disease in which micrometastases are already present in other organs by the time the breast cancer is diagnosed. Chemotherapeutic agents perform a systemic “sweep” of the body to reduce the chances that distant tumors will start growing. Chemotherapy may be indicated for women with tumors larger than 1 cm, positive lymph nodes, or cancer of an aggressive type. Chemotherapy is prescribed in cycles, with each period of treatment followed by a rest period. Treatment typically lasts 3 to 6 months, depending on the dose used and the woman’s health status. Different classes of drugs affect different aspects of cell division and are used in combinations or “cocktails.” The most active and commonly used

chemotherapeutic agents for breast cancer include alkylating agents, anthracyclines, antimetabolites, and vinca alkaloids. Fifty or more chemotherapeutic agents can be used to treat breast cancer; however, a combination drug approach appears to be more effective than a single drug treatment (ACS, 2015g). Refer to Evidence-Based Practice 6.1. Side Effects. Side effects of chemotherapy depend on the agents used, the intensity of dosage, the dosage schedule, the type and extent of cancer, and the client’s physical and emotional status. Nurses need to remain current in order to accommodate new treatments and the side effect profiles. This knowledge is vital to providing evidence-based care for breast cancer women receiving these treatments (Bourdeanu & Lui, 2015). However, typical side effects include nausea and vomiting, diarrhea or constipation, hair loss, weight loss, stomatitis, fatigue, and immunosuppression. The most serious is bone marrow suppression (myelosuppression). This causes an increased risk of infection, bleeding, and a reduced red blood cell count, which can lead to anemia. Treatment of the side effects can generally be addressed through appropriate support medications such as antinausea drugs. In addition, growth-stimulating factors, such as epoetin alfa (Procrit) and filgrastim (Neupogen), help keep blood counts from dropping too low. Counts that are too low would stop or delay the use of chemotherapy. An aggressive systemic option, when other treatments have failed or when there is a strong possibility of relapse or metastatic disease, is high-dose chemotherapy with bone marrow and/or stem cell transplant. This therapy involves the withdrawal of bone marrow before the administration of toxic levels of chemotherapeutic agents. The marrow is frozen and then returned to the client after the high-dose chemotherapy is finished. Clinical trials are still researching this experimental therapy (King et al., 2015). HORMONAL THERAPY One of estrogen’s normal functions is to stimulate the growth and division of healthy cells in the breasts. However, in some women with breast cancer, this normal function contributes to the growth and division of cancer cells. The objective of endocrine therapy is to block or counter the effect of estrogen. Estrogen plays a central role in the pathogenesis of cancer, and treatment with estrogen deprivation has proven to be effective. Approximately two-thirds of women diagnosed with early-stage breast cancer have hormonesensitive disease (estrogen receptor positive and/or progesterone receptor

positive), and adjuvant hormone therapy play an essential role in reducing the risk of recurrence and improving survival (Gradishar, 2015). Several different drug classes are used to interfere or block estrogen receptors. They include selective estrogen receptor modulators (SERMs), estrogen receptor downregulators, aromatase inhibitors, luteinizing hormone-releasing hormone, progestin, and biologic response modifiers (King et al., 2015). Current recommendations for most women with ER+ breast cancer are to take a hormone-like medication—known as a SERM antiestrogenic agent—daily for up to 5 years after initial treatment. Certain areas in the female body (breasts, uterus, ovaries, skin, vagina, and brain) contain specialized cells called hormone receptors that allow estrogen to enter the cell and stimulate it to divide. SERMs enter these same receptors and act like keys, turning off the signal for growth inside the cell (King et al., 2015). The best-known SERM is tamoxifen (Nolvadex, 20 mg daily for 5 years). Although it works well in preventing further spread of cancer, it is also associated with an increased incidence of endometrial cancer, pulmonary embolus, deep vein thrombosis, hot flashes, vaginal discharge and bleeding, stroke, and cataract formation (Jager et al., 2015). Another SERM is the anti-osteoporosis drug raloxifene (Evista), which has shown promising results. It has antiestrogen effects on the breast and uterus. In recent studies involving postmenopausal women at high risk for breast cancer, raloxifene worked as well as tamoxifen in preventing breast cancer, but with fewer serious adverse effects. Both drugs cut the cancer risk in half (Bevers, 2015). It was originally marketed solely for the prevention and treatment of osteoporosis but is now used as adjunctive breast cancer therapy. Another class of endocrine agents, aromatase inhibitors, works by inhibiting the conversion of androgens to estrogens. Aromatase inhibitors include letrozole (Femara, 2.5 mg daily), exemestane (Aromasin, 25 mg daily), and anastrozole (Arimidex, 1 mg daily for 5 years), all of which are taken orally. These are usually given to women with advanced breast cancer. In recent clinical studies in postmenopausal women with breast cancer, third-generation aromatase inhibitors were shown to be superior to tamoxifen for the treatment of metastatic disease (Bevers, 2015). Side Effects. The side effects associated with these endocrine therapies include hot flashes, bone pain, bone thinning, insomnia, weight gain, depression, fatigue, nausea, cough, dyspnea, and headache (Breast Cancer Organization, 2015).

Women with hormone-sensitive cancers can live for long periods without any intervention other than hormonal manipulation, but quality-of-life issues need to be addressed in the balance between treatment and side effects. IMMUNOTHERAPY Immunotherapy, used as an adjunct to surgery, represents an attempt to stimulate the body’s natural defenses to recognize and attack cancer cells. Trastuzumab (Herceptin, 2- to 4-mg/kg intravenous infusion) is the first monoclonal antibody approved for breast cancer (NCCN, 2015). Some tumors produce excessive amounts of HER-2/neu protein, which regulates cancer cell growth. Breast cancers that overexpress the HER-2/neu protein are associated with a more aggressive form of disease and a poorer prognosis. Trastuzumab blocks the effect of this protein to inhibit the growth of cancer cells. It can be used alone or in combination with other chemotherapy to treat clients with metastatic breast disease. Although immunotherapy has shown some promise against the fight against cancer, recent data suggests that greater success will be achieved by combining it with other therapies, such as radiation (Leavy, 2015). Concept Mastery Alert Tamoxifen Versus Trastuzumab in Breast Cancer Treatment Tamoxifen is a selective estrogen receptor modulator used to prevent further spread of breast cancer in women with ER-positive breast cancer. Trastuzumab is a monoclonal antibody used in the treatment of breast cancer and is considered immunotherapy.

Side Effects. Adverse effects of trastuzumab include cardiac toxicity, vascular thrombosis, hepatic failure, fever, chills, nausea, vomiting, and pain with first infusion (Skidmore-Roth, 2015).

NURSING PROCESS FOR THE CLIENT WITH BREAST CANCER When a woman is diagnosed with breast cancer, she faces treatment that may alter her body shape, may make her feel unwell, and may not carry a certainty of cure. Nurses can support women from the time of diagnosis, through the treatments, and through follow-up after the surgical and adjunctive treatments have been completed. Allowing clients the time to ask questions and to discuss any necessary preparations for treatment is critical. As our understanding of breast disorders keeps improving, treatments continue to change. Although the goal of treatment remains improved survival, increasing emphasis is being focused on prevention. Breast cancer prevention measures focus on evaluating and reducing risk factors. Approaches for reducing breast cancer risk include lifestyle modifications (diet and physical exercise), chemoprevention (SERMs & AIs), and prophylactic surgery (bilateral salpingoopjorectomy & bilateral prophylactic mastectomy) (Euhus & Diaz, 2015). Nurses can have an impact on early detection of breast disorders, treatment, and symptom management. Women with a cancer diagnosis often experience negative emotions and nurses’ empathic response can help alleviate their distress (Alexander et al., 2014). A nurse who is involved in the woman’s treatment plan from the beginning can effectively offer support throughout the whole experience. Teamwork is important in breast screening and caring for women with breast disorders. Treatment is often fragmented between the hospital and community treatment centers, which can be emotionally traumatic for the woman and her family. The advances being made in the diagnosis and treatment of breast disorders mean that guidelines are constantly changing, requiring all health care providers to keep up to date. Informed nurses can provide support and information and, most importantly, continuity of care for the woman undergoing treatment for a breast problem. The nurse plays a particularly important role in providing psychological support and self-care teaching to clients with breast cancer. Nurses can influence both physical and emotional recovery, which are both important aspects of care

that help in improving the woman’s quality of life and the ability to survive. The nurse’s role should extend beyond helping clients; spreading the word in the community about screening and prevention is a big part in the ongoing fight against cancer. The community should see nurses as both educators and valued sources of credible information. This role will help improve clinical outcomes while achieving high levels of client satisfaction. Despite the new guidelines issued by various governmental agencies regarding BSEs, a CBE done by a professional health care provider is essential for good breast health for all women. See Box 6.1 for additional information. Remember Nancy from the chapter opener? Is her response typical of many women upon discovering a lump in their breast? Nancy confides her discovery of the lump and her worries to you. What advice would you give her?

ASSESSMENT Early breast cancer has no symptoms. The earliest sign of breast cancer is often an abnormality seen on a screening mammogram before the woman or the health care provider feels it. A healthy, asymptomatic presentation is typical. However, symptoms may include a lump in the breast that is usually nontender, fixed, and hard with irregular borders. In the woman presenting with a breast disorder, take a thorough history of the problem and explore the woman’s risk factors for breast cancer. Assess the woman for clinical manifestations of breast cancer, such as changes in breast appearance and contour, which become apparent with advancing breast cancer (ACS, 2015d). These changes include: • Continued and persistent changes in the breast • A lump or thickening in one breast • Persistent nipple irritation • Unusual breast swelling or asymmetry • A lump or swelling in the axilla • Changes in skin color or texture • Nipple retraction, tenderness, or discharge Complete a breast examination to validate the clinical manifestations and findings of the health history and risk factor assessment. The CBE involves both inspection and palpation (Box 6.1). Helpful characteristics in evaluating palpable breast masses are described in Table 6.5. If a lump can be palpated, the cancer has been there for quite some time. Be cognizant of the impact that breast cancer has on a woman’s emotional state, coping ability, and quality of life. Women may experience sadness, vulnerability, loss of control, alteration of body image and integrity, anger, the illness’s impact on relationships, fear of mortality, the need to reprioritize her life, and guilt as a result of having breast cancer. However, despite potential negative outcomes, many women have a positive outlook for their future and adapt to treatment modalities with a good quality of life (Kleban & Glaser, 2015). Closely monitor clients for their psychosocial adjustment to diagnosis and treatment and be able to identify those who need further psychological intervention. By giving practical advice, the nurse can help the woman adjust to her altered body image and to accept the changes in her life. Because family members play a significant role in supporting women through

breast cancer diagnosis and treatment, assess the emotional distress of both partners during the course of treatment and, if needed, make a referral for psychological counseling. By identifying interpersonal strains, negative psychosocial side effects of cancer treatment can be minimized.

NURSING DIAGNOSIS Appropriate nursing diagnoses for a woman with a diagnosis of breast cancer might include: • Disturbed body image related to: • Loss of body part (breast) • Loss of femininity • Loss of hair due to chemotherapy • Fear related to: • Diagnosis of cancer • Prognosis of disease • Deficient knowledge related to: • Cancer treatment options • Reconstructive surgery decisions • Breast self-examination

BOX 6.1 CLINICAL BREAST EXAMINATION BY HEALTH CARE PROVIDER If the woman is deemed high risk, the nurse would then teach the woman to perform a BSE to enhance breast awareness.

Purpose: To Assess Breasts for Abnormal Findings • Inspect the breast for size, symmetry, and skin texture and color. It is common for the left breast to be slightly larger than the right. Inspect the nipples and areola. Ask the client to sit at the edge of the examination table, with her arms resting at her sides.

• Inspect the breast for masses, retraction, dimpling, or ecchymosis. • The client places her hands on her hips.

• She then raises her arms over her head so the axillae can also be inspected.

• The client then stands, places her hands on her hips, and leans forward.

• Palpate the breasts using the pads of your first three fingers and make a rotary motion on the breast. Assist the client into a supine position with her arms above her head. Place a pillow or towel under the client’s head to help spread the breasts. Three patterns might be used to palpate the breasts:

1. Spiral

2. Pie-shaped wedges

3. Vertical strip

• Compress the nipple gently between the thumb and index finger to evaluate for masses and squeeze to check for any discharge.

• Palpate the axillary area for any tenderness or lymph node enlargement. Have the client sit up and move to the edge of the examination table. While supporting the client’s arm, palpate downward from the armpit, palpating toward the ribs just below the breast.

Adapted from Ball, J. W., Dains, J. E., Flynn, J. A., Soloman, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Saunders.

TABLE 6.5 CHARACTERISTICS OF BENIGN VERSUS MALIGNANT BREAST MASSES

NURSING INTERVENTIONS Offer information, support, and perioperative care to women diagnosed with breast cancer who are undergoing treatment. Implement health promotion and disease prevention strategies to minimize the risk for developing breast cancer and to promote optimal outcomes. Remember Nancy, who discovered a breast lump? You offer to go with her to the doctor. After a full examination and several diagnostic tests, the results come back positive for breast cancer. What treatment options does Nancy have, and what factors need to be considered in selecting those options?

Providing Client Education Help the woman and her partner to prioritize the voluminous amount of information given to them so that they can make informed decisions. Explain all treatment options in detail so the client and her family understand them. By preparing an individualized packet of information and reviewing it with the woman and her partner (if applicable), the nurse can help the woman understand her specific type of cancer, the diagnostic studies and treatment options she may choose, and the goals of treatment. For example, nurses play an important role in educating women about the use of endocrine therapies, observing women’s experiences with treatment, and communicating those observations to their primary health care providers to make dosage adjustments, in addition to contributing to the knowledge base of endocrine therapy in the treatment of breast cancer. Providing information is a central role of the nurse in caring for the woman with a diagnosis of breast cancer. This information can be given via telephone counseling, one-to-one contact, and pamphlets. Telephone counseling with women and their partners may be an effective method to improve symptom management and quality of life. Educate women on living with risk, maintaining quality of life, and participating in support groups (Strayer & Schub, 2014).

Providing Emotional Support The diagnosis of cancer affects all aspects of life for a woman and her family. The threatening nature of the disease and feelings of uncertainty about the future can lead to anxiety and stress. Address the woman’s need for: • Information about diagnosis and treatment • Physical care while undergoing treatments • Contact with supportive people • Education about disease, options, and prevention measures • Discussion and support by a caring, competent nurse Reassure the client and her family that the diagnosis of breast cancer does not necessarily mean imminent death, a decrease in attractiveness, or diminished sexuality. Encourage the woman to express her fears and worries. Be available to listen and address the woman’s concerns in an open manner to help her toward recovery. All aspects of care must include sensitivity to the client’s personal efforts to cope and heal. Some women will become involved in organizations or charities that support cancer research; they may participate in breast cancer walks to raise awareness or become a Reach to Recovery volunteer to help others. Each woman copes in her own personal manner, and all of these efforts can be positive motivators for her own healing. To help women cope with the diagnosis of breast cancer, the ACS launched Reach to Recovery more than 30 years ago. Specially trained breast cancer survivors give women and their families’ opportunities to express their feelings, verbalize their fears, and get answers. Recovery volunteers can also, when appropriate, provide a temporary breast form and give information on types of permanent prostheses, as well as lists of where those items are available in the community. Most importantly, Reach to Recovery volunteers offer understanding, support, and hope through face-to-face visits or by telephone; they are proof that people can survive breast cancer and live productive lives. National contact information is 1-800-ACS-2345.

Providing Postoperative Care For the woman who has had surgery to remove a malignant breast lump or an entire breast, excellent postoperative nursing care is crucial. Tell the woman what to expect in terms of symptoms and when they usually occur during treatment and after surgery. This allows women to anticipate these symptoms and proactively employ management strategies to improve their cancer experience. Postoperative care includes immediate postoperative care, pain management, care of the affected arm, wound care, mobility care, respiratory care, emotional care, referrals, and educational needs.

Immediate Postoperative Care Assess the client’s respiratory status by auscultating the lungs and observing the breathing pattern. Assess circulation; note vital signs, skin color, and skin temperature. Observe the client’s neurologic status by evaluating the level of alertness and orientation. Monitor the wound for amount and color of drainage. Monitor the intravenous lines for patency, correct fluid, and rate. Assess the drainage tube for amount, color, and consistency of drainage.

Pain Management Provide analgesics as needed. Reassure the woman that her pain will be controlled. Teach the woman how to communicate her pain intensity on a scale of 0 to 10, with 10 being the worst pain imaginable. Assess the client’s pain level frequently and anticipate pain before assisting the woman to ambulate.

Affected Arm Care Elevate the affected arm on a pillow to promote lymph drainage. Make sure that no treatments are performed on the affected arm, including laboratory draws, intravenous lines, blood pressures, and so on. Place a sign above the bed to warn others not to touch the affected arm.

Wound Care Observe the wound often and empty drainage reservoirs as needed. Tell the client to report any evidence of infection early, such as fever, chills, or any area of redness or inflammation along the incision line. Also tell the client to report any increase in drainage, foul odor, or separation at the incision site.

Mobility Care Perform active range-of-motion and arm exercises as ordered. Encourage selfcare activities for successful rehabilitation. Perform dressing and drainage care; explain the care during the procedure.

Respiratory Care Assist with turning, coughing, and deep breathing every 2 hours. Explain that this helps to expand collapsed alveoli in the lungs, promotes faster clearance of inhalation agents from the body, and prevents postoperative pneumonia and atelectasis.

Emotional Care and Referrals Encourage the client to participate in her care. Assess her coping strategies preoperatively. Explain possible body image concerns after discharge. Promote the ACS web sites, which provide the latest cancer therapy news. Encourage the client to attend local support groups for breast cancer survivors, such as Reach to Recovery.

Educational Needs Provide follow-up information about adjunctive therapy. Explain that radiation therapy may start within weeks postoperatively. Discuss chemotherapy, its side effects and cycles, home care during treatment, and future monitoring strategies. Explain hormonal therapy, including antiestrogens or aromatase inhibitors. Teach progressive arm exercises to minimize lymphedema. Explain that ongoing surveillance is needed to detect recurrence of cancer or a new primary site and that the client will typically see the health care provider every 6 months. Nancy underwent a mastectomy with radiation and chemotherapy. What follow-up care is needed? How can the nurse assist Nancy to cope with her uncertain future? What community resources might help her?

IMPLEMENTING HEALTH PROMOTION AND DISEASE PREVENTION STRATEGIES In the past, most women assumed that there was little they could do to reduce their risk of developing breast cancer, but since the 1970s significant advances have been made in the diagnosis and treatment of breast cancer. Mortality rates have decreased since 1990, particularly in women 1 cm above the hymenal ring. • Stage II: The prolapsed organ extends ∼1 cm below the hymenal ring. • Stage III: The prolapsed organ extends 2 to 3 cm below the hymenal ring. • Stage IV: The vagina is completely everted or the prolapsed organ is >3 cm below the hymenal ring (Riss & Koch, 2015).

FIGURE 7.1 Types of pelvic prolapses. (A) Normal. (B) Rectocele and cystocele. (C) Enterocele. (D) Uterine prolapse.

Etiology Anatomic support of the pelvic organs is mainly provided by the levator ani muscle complex and the connective tissue attachments of the pelvic organ fascia. Dysfunction of one or both of these components can lead to loss of support and eventually POP. Weakened pelvic floor muscles also prevent complete closure of the urethra, resulting in urine leakage during physical stress. This problem is not limited to older women: Urinary incontinence has been documented in women of varying ages, including young (35 in), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol level 65 years old with an adequate screening history. Women who have had a hysterectomy should stop screening. Women who have received the HPV vaccine should be screened according to the same guidelines as women who have not been vaccinated. In addition, women must have a clear understanding of the results of Pap smear testing and follow-up guidelines. High-risk women should continue to have annual Pap smears throughout their life (Table 8.2). Pap smear results are classified using the Bethesda System (Box 8.1), which provides a uniform diagnostic terminology that allows clear communication

between the laboratory and the health care provider. The information provided by the laboratory is divided into three categories: specimen adequacy, general categorization of cytologic findings, and interpretation/result (ACS, 2015h). TABLE 8.2 PAP SMEAR GUIDELINES

Therapeutic Management Treatment for abnormal Pap smears depends on the severity of the results and the health history of the woman. Therapeutic choices all involve destroying as many affected cells as possible. With the introduction of multimodality therapy for cervical cancer, many women will be long-term survivors in need of comprehensive surveillance care. Obesity and smoking are significant comorbidities that may complicate care in cervical cancer survivors. Nurses can focus their interventions at modifying these risk factors to increase the quality of life for cervical cancer survivors. Box 8.2 describes treatment options. Using the Bethesda System, the following management guidelines for abnormal Pap results were developed by the NCI to provide direction to health care providers and clients: • ASC-US: Repeat the Pap smear in 4 to 6 months or refer for colposcopy. • ASC-H: Refer for colposcopy with HPV testing. • Atypical glandular cells (AGC) and adenocarcinoma in situ (AIS): Immediate colposcopy; follow-up is based on the findings.

BOX 8.1 THE BETHESDA SYSTEM FOR CLASSIFYING PAP SMEARS Specimen Type: Conventional Pap smear vs. liquid-based Specimen Adequacy: Satisfactory or unsatisfactory for evaluation General Categorization: (optional) • Negative for intraepithelial lesion or malignancy • Epithelial cell abnormality. See interpretation/result Automated Review: If case was examined by automated device or not Ancillary Testing: Provides a brief description of the test methods and report results so that the health care provider understands Interpretation/Result: • Negative for intraepithelial lesion or malignancy • Organisms: Trichomonas vaginalis; fungus; bacterial vaginosis; herpes simplex • Other non-neoplastic findings: Reactive cellular changes associated with inflammation, radiation, intrauterine devices, atrophy • Other: Endometrial cells in a woman >40 years of age • Epithelial cell abnormalities: • Squamous cell • Atypical squamous cells • Of undetermined significance (ASC-US) • Cannot exclude HSIL (ASC-H) • Low-grade squamous intraepithelial lesion (LSIL) • Encompassing HPV/mild dysplasia/CIN-1 • High-grade squamous intraepithelial lesion (HSIL) • Encompassing moderate and severe dysplasia CIS/CIN-2 and CIN-3 • With features suspicious for invasion • Squamous cell carcinoma

• Glandular cell: Atypical • Endocervical, endometrial, or glandular cells • Endocervical cells—favor neoplastic • Glandular cells—favor neoplastic • Endocervical adenocarcinoma in situ • Adenocarcinoma • Endocervical, endometrial, extrauterine • Other malignant neoplasms (specify) Educational Notes and Suggestions: (optional) Adapted from American Society of Cytopathology. (2015). The Bethesda System for reporting cervical cytology: Definitions, criteria and explanatory notes. Retrieved from http://www.cytopathology.org/thebethesda-system-for-reporting-cervical-cytology-definitions-criteria-and-explanatory-notes-3rdedition/; National Cancer Institute [NCI]. (2015k). Cervical cancer prevention. Retrieved from http://www.cancer.gov/cancertopics/pdq/prevention/cervical/Patient/page3; and Schuiling, K. D., & Likis, F. E. (2016). Women’s gynecologic health (3rd ed.). Sudbury, MA: Jones & Bartlett.

Colposcopy is a microscopic examination of the lower genital tract using a magnifying instrument called a colposcope. Specific patterns of cells that correlate well with certain histologic findings can be visualized.

BOX 8.2 TREATMENT OPTIONS FOR CERVICAL CANCER • Cryotherapy—destroys abnormal cervical tissue by freezing with liquid nitrogen, Freon, or nitrous oxide. Studies show a 90% cure rate (NCI, 2015g). Healing takes up to 6 weeks, and the client may experience a profuse, watery vaginal discharge for 3 to 4 weeks. • Cone biopsy or conization—removes a cone-shaped section of cervical tissue. The base of the cone is formed by the ectocervix (outer part of the cervix) and the point or apex of the cone is from the endocervical canal. The transformation zone is contained within the cone sample. The cone biopsy is also a treatment and can be used to completely remove any precancers and very early cancers. Two methods are commonly used for cone biopsies: • LEEP (loop electrosurgical excision procedure) or LLETZ (large loop excision of the transformation zone)—the abnormal cervical tissue is removed with a wire that is heated by an electrical current. For this procedure, a local anesthetic is used. It is performed in the health care provider’s office in approximately 10 minutes. Mild cramping and bleeding may persist for several weeks after the procedure. • Cold knife cone biopsy—a surgical scalpel or a laser is used instead of a heated wire to remove tissue. This procedure requires general anesthesia and is done in a hospital setting. After the procedure, cramping and bleeding may persist for a few weeks. • Laser therapy—destroys diseased cervical tissue by using a focused beam of high-energy light to vaporize it (burn it off). After the procedure, the woman may experience a watery brown discharge for a few weeks. Very effective in destroying precancers and preventing them from developing into cancers. • Hysterectomy—removes the uterus and cervix surgically • Radiation therapy—delivered by internal radium applications to the cervix or external radiation therapy that includes lymphatics of the pelvis • Chemoradiation—weekly cisplatin therapy concurrent with radiation. Investigation of this therapy is ongoing (ACS, 2015h).

Nursing Assessment Obtain a thorough history and physical examination of the woman. Investigate her history for risk factors such as: • Early age at first intercourse (within 1 year of menarche) • Lower socioeconomic status • Promiscuous male partners • Unprotected sexual intercourse • Family history of cervical cancer (mother or sisters) • Sexual intercourse with uncircumcised men • Female offspring of mothers who took diethylstilbestrol (DES) • Infections with genital herpes or chronic chlamydia • Multiple sex partners • Cigarette smoking • Immunocompromised state • HIV infection • Oral contraceptive use • Moderate dysplasia on Pap smear within past 5 years • HPV infection (CDC, 2015e) Question the woman about any signs and symptoms. Clinically, the first sign is abnormal vaginal bleeding, usually after sexual intercourse. Also be alert for reports of vaginal discomfort, malodorous discharge, and dysuria. In some cases, the woman is asymptomatic, with detection occurring at an annual gynecologic examination and Pap test. Perform a physical examination. Inspect the perineal area for vaginal discharge or genital warts. Perform or assist with a pelvic examination, including the collection of a Pap smear as indicated (Nursing Procedure 8.1).

Take Note!

Suspect advanced cervical cancer in women with pelvic, back, or leg pain, weight loss, anorexia, weakness and fatigue, and fractures. Prepare the woman for further diagnostic testing if indicated, such as a colposcopy. In a colposcopy, the woman is placed in the lithotomy position and her cervix is cleansed with acetic acid solution. Acetic acid makes abnormal cells appear white, which is referred to as acetowhite. These white areas are then biopsied and sent to the pathologist for assessment. Although this test is not painful, it has minor side effects (minor bleeding, cramping, and a risk of an infection developing after the biopsy), and can be performed safely in the clinic or office setting, and women may be apprehensive or anxious about it because it is done to identify and confirm potential abnormal cell growth. Some health care providers request that the woman pre-medicate with a mild analgesic such as ibuprofen prior to undergoing the procedure.

Nursing Management The nurse’s role involves primary prevention by educating women about risk factors and ways to prevent cervical dysplasia. Cervical cancer rates have decreased in the United States because of the widespread use of Pap testing, which can detect precancerous lesions of the cervix before they develop into cancer. Concept Mastery Alert Cervical Cancer Prevention The key points to remember in cervical cancer prevention are smoking cessation, limiting alcohol consumption, and encouraging teens to refrain from early sexual activity.

NURSING PROCEDURE 8.1

Assisting with Collection of a PAP Smear Purpose: To Obtain Cells From the Cervix for Cervical Cytology Screening 1. Explain procedure to the client (Fig. A). 2. Instruct client to empty her bladder. 3. Wash hands thoroughly. 4. Assemble equipment, maintaining sterility of equipment (Fig. B). 5. Position client on stirrups or foot pedals so that her knees fall outward. 6. Drape client with a sheet for privacy, covering the abdomen but leaving the perineal area exposed. 7. Open packages as needed. 8. Encourage client to relax. 9. Provide support to client as the practitioner obtains a sample by spreading the labia; inserting the speculum; inserting the cytobrush and swabbing the endocervix; and inserting the plastic spatula and swabbing the cervix (Figs. C–H).

10. Transfer specimen to a container (Fig. I) or a slide. If a slide is used, spray the fixative on the slide holding the spray container about 12 inches away from the slide 11. Place sterile lubricant on the practitioner’s fingertip when indicated for the bimanual examination. 12. Wash hands thoroughly. 13. Label specimen according to facility policy. 14. Rinse reusable instruments and dispose of waste appropriately (Fig. J). 15. Wash hands thoroughly. 16. Assist the client up after the exam is completed.

Adapted from King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, MA: Jones & Bartlett Learning; and Schuiling, K. D., & Likis, F. E. (2016). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Gardasil and Cervarix are vaccines approved by the United States Food and Drug Administration to protect girls and women from HPV and thus prevent cervical cancer. The vaccines prevent infection from four HPV types: HPV 6, 11, 16, and 18. These types are responsible for 70% of cervical cancers and 90% of genital warts (NCI, 2015h). Clinical trials indicate that the vaccine has high efficacy in preventing persistent HPV infection, cervical cancer precursor lesions, vaginal and vulvar cancer precursor lesions, and genital warts (NCI, 2015h). The vaccine is administered by intramuscular injection, and the recommended schedule is a three-dose series with the second and third doses administered 2 and 6 months after the first dose. The recommended age for vaccination of females is 9 to 26 years (Castle & Schmeler, 2015). The vaccines protect against infection with these types of HPV for 6 to 8 years. It is not known if the protection lasts longer. The vaccines do not protect women who are

already infected with HPV (NCI, 2015h). However, the vaccine is not a substitute for routine cervical cancer screening, and vaccinated women should have Pap smears as recommended. Focus primary prevention education on the following: • Identify high-risk behaviors in clients and teach them how to reduce such behaviors • Take steps to prevent STIs. • Avoid early sexual activity. • Faithfully use barrier methods of contraception. • Avoid smoking and drinking. • Receive the HPV vaccine. • Instruct women on the importance of screening for cervical cancer by having annual Pap smears. Outline the proper preparation before having a Pap smear (Teaching Guidelines 8.3). Reinforce specific guidelines for screening. • Interferes with visual evaluation of the sample (Schuiling & Likis, 2016).

Teaching Guidelines 8.3

STRATEGIES TO OPTIMIZE PAP SMEAR RESULTS • Schedule your Pap smear appointment about 2 weeks (10 to 18 days) after the first day of your last menses to increase the chance of getting the best sample of cervical cells without menses. • Refrain from intercourse for 48 hours before the test because additional matter such as sperm can obscure the specimen. • Do not douche within 48 hours before the test to prevent washing away cervical cells that might be abnormal. • Do not use tampons, birth control foams, jellies, vaginal creams, or vaginal medications for 72 hours before the test, because they could cover up or obscure the cervical cell sample. • Cancel your Pap appointment if vaginal bleeding occurs, because the presence of blood cells interferes with visual evaluation of the sample.

Nurses also can advocate for clients by making sure that the Pap smear is sent to an accredited laboratory for interpretation. Doing so reduces the risk of falsenegative results. The identification and treatment of early precancerous lesions is critical to prevention of cervical cancer. Prevention measures should include educating women that the risk of infection can be reduced by delaying the onset of sexual activity, decreasing the number of sexual partners, using condoms consistently, and never start smoking. Secondary prevention focuses on reducing or limiting the area of cervical dysplasia. Tertiary prevention focuses on minimizing disability or the spread of cervical cancer. Explain in detail all procedures that might be needed. Encourage the client who has undergone any cervical treatment to allow the pelvic area to rest for approximately 1 month. Discuss this rest period with the client and her partner to gain his cooperation. Outline alternatives to vaginal intercourse, such as cuddling, holding hands, and kissing. Remind the woman about any follow-up procedures that are needed and assist her with scheduling if necessary. Tertiary prevention of cervical cancer involves the diagnosis and treatment of confirmed cases of cancer. Treatment is typically through surgery, radiotherapy, and, frequently, chemotherapy. Palliative care is provided to women when the disease has already reached an incurable stage. Knowing that the woman and her family have been told about her prognosis, the nurse is in a position to support them when the impact of the diagnosis is realized. Throughout the process, provide emotional support to the woman and her family. During the decision-making process, the woman may be overwhelmed by the diagnosis and all the information being presented. Refer the woman and her family to appropriate community resources and support groups as indicated. It is crucial for all women to be given correct information regarding safe sexual practices, informed about the preventive role of the HPV vaccination, and become educated about the role of the Pap test as a secondary screening measure for cervical cancer. The emotional needs of the woman diagnosed with cancer can best be met by a warm, friendly personality, an attitude of empathy rather than sympathy, and skilled communication. Nurses across all settings are in a powerful position to be advocates for safe health care practices of women through education at personal, community, and national levels.

VAGINAL CANCER Vaginal cancer is a rare malignant tissue growth arising in the vagina. Only about 1 of every 1,100 women will develop vaginal cancer in her lifetime. In 2015, the ACS (2015i) estimate that more than 4,000 new cases will be diagnosed in women and that over 900 of those women will die from this cancer. The peak incidence of vaginal cancer occurs at 60 to 65 years of age. The prognosis of vaginal cancer depends largely on the stage of disease and the type of tumor. The overall 5-year survival rate for squamous cell carcinoma is about 42%; that for adenocarcinoma is about 78% (NCI, 2015i). Vaginal cancer can be effectively treated, and when found early it is often curable.

Pathophysiology The etiology of vaginal cancer has not been identified. Malignant diseases of the vagina are either primary vaginal cancers or metastatic forms from adjacent or distant organs. About 80% of vaginal cancers are metastatic, primarily from the cervix and endometrium. These cancers invade the vagina directly. Cancers from distant sites that metastasize to the vagina through the blood or lymphatic system are typically from the colon, kidneys, skin (melanoma), or breast. Tumors in the vagina commonly occur on the posterior wall and spread to the cervix or vulva (NCI, 2015i). Squamous cell carcinomas that begin in the epithelial lining of the vagina account for about 85% of vaginal cancers. This type of cancer usually occurs in women over age 50. The SCCs develop slowly over a period of years, commonly in the upper third of the vagina. They tend to spread early by directly invading the bladder and rectal walls. They also metastasize through blood and lymphatics. The remaining 15% are adenocarcinomas, which differ from SCC by an increase in pulmonary metastases and supraclavicular and pelvic node involvement (ACS, 2015j).

Therapeutic Management Treatment of vaginal cancer depends on the type of cells involved and the stage of the disease. If the cancer is localized, radiation, laser surgery, or both may be used. If the cancer has spread, radical surgery might be needed, such as a hysterectomy, or removal of the upper vagina with dissection of the pelvic nodes in addition to radiation therapy.

Nursing Assessment Begin the history and physical examination by reviewing for risk factors. Although direct risk factors for the initial development of vaginal cancer have not been identified, associated risk factors include advancing age (over 60 years old), previous pelvic radiation, exposure to DES in utero, vaginal trauma, history of genital warts (HPV infection), HIV infection, cervical cancer, chronic vaginal discharge, smoking, and low socioeconomic level (ACS, 2015k). Question the woman about any symptoms. Most women with vaginal cancer are asymptomatic. Those with symptoms have painless vaginal bleeding (often after sexual intercourse), abnormal vaginal discharge, dyspareunia, dysuria, constipation, and pelvic pain (NCI, 2015i). During the physical examination, observe for any obvious vaginal discharge or genital warts or changes in the appearance of the vaginal mucosa. Anticipate colposcopy with biopsy of suspicious lesions to confirm the diagnosis.

Nursing Management Nursing management for this cancer is similar to that for other reproductive cancers, with emphasis on sexuality counseling and referral to local support groups. Women undergoing radical surgery need intensive counseling about the nature of the surgery, risks, potential complications, changes in physical appearance and physiologic function, and sexuality alterations. Nurses should focus their care on client education, client pain and symptom management, communication with the woman and her family, and coordination of care across of all settings.

VULVAR CANCER Vulvar cancer is an abnormal neoplastic growth on the external female genitalia including the clitoris, vaginal lips, and opening to the vagina (Fig. 8.5). Vulvar cancer accounts for approximately 5% of all female genital malignancies. In the United States, women have a 1 in 333 chance of developing vulvar cancer at some point in their lifetime. It is the fourth most common gynecologic cancer, after endometrial, ovarian, and cervical cancers (NCI, 2015j). The ACS (2015h) estimates that, in 2015, over 5,000 cancers of the vulva will be diagnosed in the United States and over 1,000 women will die of this cancer. When detected early, it is highly curable. Typically, vulvar cancer can be advanced at diagnosis, though it is a visible cancer that can be seen by the woman as an abnormal lesion/growth in her genital region. Vulvar cancer is found most commonly in older women in their mid-60s to mid-70s, but the incidence in women younger than 35 years old has increased during the past few decades. The overall 5-year survival rate when lymph nodes are not involved is 90%, but it drops to 50% to 70% when the lymph nodes have been invaded (ACS, 2015m).

Pathophysiology Vulvar cancer can be classified into two groups according to predisposing factors: the first type correlates with a HPV infection and occurs mostly in younger women. The second group is not HPV associated and occurs in elderly women without cancerous disorders. Approximately 80% of vulvar tumors are squamous cell carcinomas. This type of cancer forms slowly over several years and is usually preceded by precancerous changes. These precancerous changes are termed vulvar intraepithelial neoplasia (VIN). The two major types of VIN are classic (undifferentiated) and simplex (differentiated). Classic VIN, the more common one, is associated with HPV infection (genital warts due to types 16, 18, 31, 33, 35, 45, and 54) and smoking (Alkatout et al., 2015). It typically occurs in women between 30 and 40 years old. In contrast to classic VIN, simplex VIN usually occurs in postmenopausal women and is not associated with HPV but chronic irritation over time (Cancer.Net, 2015b).

Screening and Diagnosis Annual vulvar examination is the most effective way to prevent vulvar cancer. Careful inspection of the vulva during routine annual gynecologic examinations remains the most productive diagnostic technique. Liberal use of biopsies of any suspicious vulvar lesion is usually necessary to make the diagnosis and to guide treatment. However, many women do not seek health care evaluation for months or years after noticing an abnormal lump or lesion. Leading presenting complaints of women with vulvar cancer include dyspareunia, long history of pruritus, ulcers on the “outside” genitalia, vulvar swelling, vulvar bleeding, and urinary problems (Alkatout et al., 2015). The diagnosis of vulvar cancer is made by a biopsy of the suspicious lesion, which is usually found on the labia majora.

FIGURE 8.5 Vulvar cancer. (The Anatomical Chart Company. [2009]. Atlas of pathophysiology [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins.)

Take Note! Vulvar pruritus or a lump is present in the majority of women with vulvar cancer. Lumps should be biopsied even if the woman is asymptomatic.

Therapeutic Management Treatment varies depending on the extent of the disease. Laser surgery, cryosurgery, or electrosurgical incision may be used. Larger lesions may need more extensive surgery and skin grafting. The traditional treatment for vulvar cancer has been radical vulvectomy, but more conservative techniques are being used to improve psychosexual outcomes and less morbidity, without compromising survival (Forner, Dakhil, & Lampe, 2015).

Nursing Assessment Typically, no single specific clinical symptom heralds this disease, so diagnosis is often delayed significantly. Therefore, it is important to review the woman’s history for risk factors such as: • Exposure to HPV type 16 • Age over 50 years • HIV infection • VIN • Lichen sclerosus (a patchy skin disorder) • Melanoma or atypical moles • Exposure to HSV type 2 • Multiple sex partners • Smoking • Herpes simplex • History of breast cancer • Immune suppression • Hypertension • Diabetes mellitus • Obesity (ACS, 2015n). In most cases, the woman reports persistent vulvar itching, burning, and edema that do not improve with the use of creams or ointments. A history of condyloma, gonorrhea, and herpes simplex are some of the factors for greater risk for VIN. Diagnosis of vulvar carcinoma is often delayed. Women neglect to seek treatment for an average of 6 months from the onset of symptoms. In addition, a delay in diagnosis often occurs after the client presents to her physician. In many cases, a biopsy of the lesion is not performed until the problem fails to respond to numerous topical therapies. During the physical examination, observe for any masses or thickening of the vulvar area. A vulvar lump or mass is most often noted. The vulvar lesion is usually raised and may be fleshy, ulcerated, leukoplakic (looking like white patches), or warty. The cancer

can appear anywhere on the vulva, although about three fourths arise primarily on the labia (Vargo & Beriwal, 2015). Less commonly, the woman may present with vulvar bleeding, discharge, dysuria, and pain.

Nursing Management Women with vulvar cancer must clearly understand their disease, treatment options, and prognosis. To accomplish this, provide information and establish effective communication with the client and her family. Act as an educator and advocate. Teach the woman about healthy lifestyle behaviors, such as smoking cessation and measures to reduce risk factors. For example, instruct the woman how to examine her genital area, urging her to do so monthly between menstrual periods. Tell her to look for any changes in appearance (e.g., whitened or reddened patches of skin); changes in feel (e.g., areas of the vulva becoming itchy or painful); or the development of lumps, moles (e.g., changes in size, shape, or color), freckles, cuts, or sores on the vulva. Urge the woman to report these changes to the health care provider (ACS, 2015m). Teach the woman about preventive measures such as not wearing tight undergarments and not using perfumes and dyes in the vulvar region. Also educate her about the use of barrier methods of birth control (e.g., condoms) to reduce the risk of contracting HIV, HSV, and HPV. Other prevention measures include delaying first sexual intercourse, avoiding sexual intercourse with multiple partners, not starting smoking or quitting if a smoker already, and getting the HPV vaccine available for all boys and girls and women between 9 and 26 years old. For the woman diagnosed with vulvar cancer, provide information and support. Discuss potential changes in sexuality if radical surgery is performed. Encourage her to communicate openly with her partner. Refer her to appropriate community resources and support groups. All nurses should come in contact with women in their clinical practices who have the potential to become cancer clients, already have suspicious signs or symptoms of cancer, are already undergoing cancer treatment, or are terminal cancer clients. The nurse should be involved with all aspects of cancer, from diagnosis through palliative care. Each nurse has an obligation to keep informed of current developments in the cancer field to function effectively and be able to educate the woman and her family. KEY CONCEPTS Women have a one-in-three lifetime risk of developing cancer, and one out of

every four deaths is from cancer; thus, nurses must focus on screening and educating all women regardless of risk factors. The nurse plays a key role in offering emotional support, determining appropriate sources of support, and helping the woman use effective coping strategies when facing a diagnosis of cancer of the reproductive tract. Although reproductive tract cancer is rare during pregnancy, the woman’s vigilance and routine screenings should continue throughout. A woman’s sexuality and culture are inextricably interwoven, and it is essential that nurses working with women of various cultures recognize this and remain sensitive to the vast changes that will take place when the diagnosis of cancer is made. Ovarian cancer is the eighth most common cancer among women and the fourth most common cause of cancer deaths for women in the United States, accounting for more deaths than any other cancer of the reproductive system. Ovarian cancer has been described as the “overlooked disease” or “silent killer” because women and health care practitioners often ignore or rationalize early symptoms. It is typically diagnosed in advanced stages. Unopposed endogenous and exogenous estrogens, obesity, nulliparity, menopause after the age of 52 years, and diabetes are the major etiologic risk factors associated with the development of endometrial cancer. The American Cancer Society recommends that women should be informed about risks and symptoms of endometrial cancer at the onset of menopause and strongly encouraged to report any unexpected bleeding or spotting to their health care providers. Malignant diseases of the vagina are either primary vaginal cancers or metastatic forms from adjacent or distant organs. Vaginal cancer tumors can be effectively treated and, when found early, are often curable. Cervical cancer incidence and mortality rates have decreased noticeably in the past several decades, with most of the reduction attributed to the Pap test, which detects cervical cancer and precancerous lesions. The nurse’s role involves primary prevention of cervical cancer through education of women regarding risk factors and preventive vaccines to avoid cervical dysplasia. About 80% of the diagnosed vaginal cancers are metastatic, primarily from the cervix and endometrium. These cancers invade the vagina directly. Vulvar

cancer is often delayed significantly because there is no single specific clinical symptom that heralds it. The most common presentation is persistent vulvar itching that does not improve with the application of creams or ointments.

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123–129). Oxford, UK: Karger Publishers. Kim, R. H., & Chu, Q. D. (2015). Breast cancer during pregnancy. In Surgical oncology (pp. 163–168). New York, NY: Springer Publishers. King, T. L, Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, MA: Jones & Bartlett Learning. Li, Y., Zhao, J., Zhang, Q., & Wang, Y. (2015). Does ovarian stimulation for IVF increase gynecological cancer risk? A systematic review and meta-analysis. Reproductive BioMedicine Online, 31(1), 20–29. Liede, A., Sun, P., & Narod, S. (2015). Effect of breast cancer after ovarian cancer on mortality for BRCA mutation carriers. JAMA Surgery, 150(5), 490–491. Lofters, A. K. (2015). Ethnicity and breast cancer stage at diagnosis: An issue of health equity. Current Oncology, 22(2), 80–81. Matsumoto, K., Onda, T., & Yaegashi, N. (2015). Pharmacotherapy for recurrent ovarian cancer: Current status and future perspectives. Japanese Journal of Clinical Oncology, 45(5), 408--410. Mayo Clinic. (2015). Cancer prevention: 7 steps to reduce your risk. Retrieved from http://www.mayoclinic.org/cancer-prevention/art-20044816; Memorial Sloan Kettering Cancer Center. (2015). Ovarian cancer risk factors. Retrieved from http://www.mskcc.org/cancer-care/adult/ovarian/risk-factors Moses, S. (2015). Endometrial cancer risk factors. Family Practice Notebook. Retrieved from http://www.fpnotebook.com/Gyn/HemeOnc/EndmtrlCncrRskFctr.htm National Cancer Institute [NCI]. (2015a). SEER cancer statistics review. Retrieved from http://seer.cancer.gov/csr/1975_2010/ National Cancer Institute [NCI]. (2015b). The burden of cancer. Retrieved from http://www.cancer.gov/cancertopics/pdq/prevention/overview/HealthProfessional National Cancer Institute [NCI]. (2015c). General cancer prevention. Retrieved from http://www.cancer.gov/cancertopics/prevention#General+Cancer+Prevention+Information National Cancer Institute [NCI]. (2015d). General information about ovarian epithelial cancer. Retrieved from http://www.cancer.gov/cancertopics/pdq/treatment/ovarianepithelial/healthprofessional National Cancer Institute [NCI]. (2015e). Stat fact sheets: Endometrial cancer. Retrieved from http://seer.cancer.gov/statfacts/html/corp.html National Cancer Institute [NCI]. (2015f). Endometrial cancer. Retrieved from http://www.cancer.gov/cancertopics/types/endometrial National Cancer Institute [NCI]. (2015g). Screening and testing to detect cervical cancer. Retrieved from http://www.cancer.gov/cancertopics/screening/cervical National Cancer Institute [NCI]. (2015h). Human papillomavirus (HPV) vaccines. Retrieved from http://www.cancer.gov/cancertopics/factsheet/prevention/HPV-vaccine National Cancer Institute [NCI]. (2015i). General information about vaginal cancer. Retrieved from

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CHAPTER WORKSHEET MULTIPLE CHOICE QUESTIONS 1. When describing ovarian cancer to a local women’s group, the nurse states that ovarian cancer often is not diagnosed early because: a. The disease progresses very slowly. b. The early stages produce very vague symptoms. c. The disease usually is diagnosed only at autopsy. d. Clients do not follow up on acute pelvic pain. 2. A postmenopausal woman reports that she has started spotting again. Which of the following would the nurse do? a. Instruct the client to keep a menstrual diary for the next few months. b. Tell her not to worry, since this a common but not serious event. c. Have her start warm-water douches to promote healing. d. Anticipate that the doctor will assess her endometrium thickness. 3. Which of the following would the nurse identify as the priority psychosocial need for a women diagnosed with reproductive cancer? a. Research findings b. Hand-holding

c. Cheerfulness d. Offering of hope 4. When teaching a group of women about screening and early detection of cervical cancer, the nurse would include which of the following as most effective? a. Fecal occult blood test b. CA-125 blood test c. Pap smear and HPV test d. Sigmoidoscopy 5. After teaching a group of students about reproductive tract cancers, the nursing instructor determines that the teaching was successful when the students identify which of the following as the deadliest type of female reproductive cancer? a. Vulvar b. Ovarian c. Endometrial d. Cervical 6. The nurse is attempting to reassure her obese female client about the discovery of an ovarian cyst after her pelvic exam. Which of the following statements is true concerning ovarian cysts? They are: a. Frequently seen in polycystic kidney disease b. Always painful and need to be removed surgically c. A precursor to ovarian carcinoma d. Part of a syndrome that includes hypertension and diabetes 7. Which of the following is considered a risk factor for vulvar cancer? a. Vitamin B12 deficiency b. Epstein–Barr virus c. Human papillomavirus d. Adenovirus

CRITICAL THINKING EXERCISES 1. A 27-year-old sexually active White woman visits the Health Department family planning clinic and requests information about the various available methods of contraception. In taking her history, the nurse learns that she started having sex at age 15 and has had multiple sex partners since then. She smokes two packs of cigarettes daily. Because she has been unemployed for a few months, her health insurance policy has lapsed. She has never previously obtained any gynecologic care. a. Based on her history, which risk factors for cervical cancer are present? b. What recommendations would you make for her and why? c. What are this client’s educational needs concerning health maintenance? 2. A 60-year-old nulliparous woman presents to the gynecologic oncology clinic after her health care provider palpated an adnexal mass on her right ovary. In taking her history, the nurse learns that she has experienced mild abdominal bloating and weight loss for the past several months but felt fine otherwise. She was diagnosed with breast cancer 15 years ago and was treated with a lumpectomy and radiation. She has occasionally used talcum powder in her perineal area over the past 20 years. A transvaginal ultrasound reveals a complex mass in the right adnexa. She undergoes a total abdominal hysterectomy and bilateral salpingooophorectomy and lymph node biopsy. Pathology confirms a diagnosis of stage III ovarian cancer with abdominal metastasis and positive lymph nodes. a. Is this client’s profile typical for a woman with this diagnosis? b. What in her history might have increased her risk for ovarian cancer? c. What can the nurse do to increase awareness of this cancer for all women?

STUDY ACTIVITIES 1. During your surgical clinical rotation, interview a female client undergoing surgery for cancer of her reproductive organs. Ask her to recall the symptoms that brought her to the health care provider. Ask her what thoughts, feelings, and emotions went through her mind before and after her diagnosis. Finally, ask her how this experience will change her life in the future.

2. Visit an oncology and radiology treatment center to find out about the various treatment modalities available for reproductive cancers. Contrast the various treatment methods and report your findings to your class. 3. Visit one of the web sites listed in the extensive list of websites provided on to explore a topic of interest concerning reproductive cancers. How correct and current is the content? What is its level? Share your assessment with your classmates. 4. Taking oral contraceptives provides protection against ___________________ cancer. 5. Two genes, BRCA1 and BRCA2, are linked with hereditary ________________ and ________________ cancers.

BRINGING IT ALL TOGETHER: CASE STUDY Jill, a 38-year old obese female with a history of infertility and irregular bleeding, returns to her OB/GYN doctor as a follow-up appointment. She had a D&C the week before to stop a profuse bleeding episode. She is informed by the doctor that her pathology report came back from the D&C showing endometrial adenocarcinoma. She is in shock over the diagnosis at her young age.

ASSESSMENT The nurse takes Jill’s history, which includes irregular menstrual cycles since her menarche. She has a BMI of 32. She takes medication to manage her diabetes and hypertension. She had been previously diagnosed with Polycystic ovary syndrome (PCOS) when she was a teenager. Her pelvic exam demonstrates an enlarged uterus. She had been to see her doctor several times because of her irregular bleeding, but she had been treated with medications until a D&C was done after months of unsuccessful drug therapy. Go to

to find questions to consider about this case.

9 Violence and Abuse

KEY TERMS acquaintance rape battered women syndrome cycle of violence date rape female genital cutting (FGC) human trafficking incest intimate partner violence (IPV) post-traumatic stress disorder (PTSD) rape sexual abuse

statutory rape

Learning Objectives Upon completion of the chapter, you will be able to: 1. Examine the incidence of violence in women. 2. Characterize the cycle of violence and appropriate interventions. 3. Evaluate the various myths and facts about violence. 4. Analyze the dynamics of rape and sexual abuse. 5. Select the resources available to women experiencing abuse. 6. Outline the role of the nurse who cares for abused women. Dorothy came to the prenatal clinic with a complaint of recurring headaches. She had been in twice this week already, but insisted she be seen today and started to cry. When the nurse called her into the examination room, Dorothy’s cell phone rang. She hurried to answer it and told the person on the other end that she was at the store. When the nurse asked if she was afraid at home, Dorothy answered “at times.” What cues did the nurse pick up on to ask that question? How frequent is this problem in women?

Words of Wisdom After being traumatized, women can decide to stay in the shallow end of the pool or they can find support and swim in the ocean.

INTRODUCTION Imagine if you were subjected to assault, rape, sexual slavery, torture, verbal abuse, mutilation, even murder—all because of your gender. It seems rarely acknowledged that violence against women and girls exists on the scale it does. Many of these females are brutalized from cradle to grave simply because of their gender. This abuse is the most pervasive human rights violation in the world today, and yet remains silent to many ears around the globe. Gender-based violence is a major global public health and human rights problem and one that often goes unrecognized and unreported. It is a common source of physical, psychological, and emotional morbidity. It occurs in all countries, irrespective of social, economic, religious, or cultural group. It affects women across race, ethnicity, age, socioeconomic status, religion, sexual orientation, and geographic boundaries. No segments of society are immune from the vestiges of this problem. Due to the unequal power relations between men and women, women are violated either in the family, in the community, or in the country in which they live. The causes are multidimensional and are social, economic, cultural, political, and religious. Pregnancy is a time of unique vulnerability to intimate partner violence (IPV) victimization because of changes in women’s physical, social, emotional, and economic needs during pregnancy. Although the true prevalence of violence during pregnancy is unclear, research suggests it is substantial and often continues into the postpartum period. Genderbased violence is one of the most rigorous challenges of women’s health and well-being; it is a harrowing worldwide public health concern with serious consequences for individuals, families, and societies (Berthold, 2015). Female-perpetrated violence against male partners receives little attention. Although women are victims of violence more frequently than men, the prevalence of violence among men nonetheless represents a significant public health concern. One out of every four men has experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime (National Coalition Against Domestic Violence, 2015). Although women can be violent in relationships with men, and also in samesex partnerships, the overwhelming burden of partner violence is borne by women at the hands of men. Nearly 4 in 10 women and 1 in 10 men in the United States have experienced rape, physical violence, and/or stalking by a

partner with IPV-related impact (WHO, 2015a). For all the strides American women have made in the past 100 years, obliterating violence against themselves is not one of them. Violence against women is a growing problem and in many countries is still accepted as part of normal behavior. According to the Federal Bureau of Investigation (FBI) (2015), up to half of all women in the United States will experience some form of physical violence during their lifetime. In North America, 40% to 60% of murders of women are committed by intimate partners (FBI, 2015). Recently, the FBI has broadened its definition of rape. The new definition, as it appears on the FBI website, is “Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.” This broader definition will have a dramatic impact on the way rape is tracked and reported nationwide (FBI, 2015). Federal funding for the problem is trickling down to local programs, but it is not reaching victims fast enough. For example, the United States has three times more shelters for animals than for battered women (Bouchet & Braswell, 2015). In many cases, a victim escapes her abuser only to be turned away from a local shelter because it is full. The number of abused women is staggering: one woman is being battered every 12 seconds in the United States (CDC, 2015a). Nurses play a major role in assessing women who have suffered some type of violence. Nurses have a central ethic of caring and an agenda of early intervention and health promotion for their clients to improve their health status and well-being. Often, after a woman is victimized, she will complain about physical ailments that will give her the opportunity to visit a health care setting. A visit to a health care agency is an ideal time for women to be assessed for violence. Because nurses are viewed as trustworthy and sensitive about very personal subjects, women often feel comfortable confiding in them and discussing these issues with them. As a professional nurse, the act of screening women seen in every health care setting is often the first step for a victim to start thinking about a better future. Remember, your words carry weight with your client who looks to you for help, support, and encouragement.

Take Note! Nurses will come in contact with violence and sexual abuse no matter what health care setting they work in. Nurses must be ready to ask the right questions

and to act on the answers, because such action could be lifesaving. This chapter addresses several types of gender-based violence: IPV, female genital cutting (FGC), human trafficking, and sexual abuse. All of these types of violence against women have devastating and costly consequences for all of society.

INTIMATE PARTNER VIOLENCE IPV is actual or threatened physical or sexual violence or psychological/emotional abuse. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and in one third to over one half of cases by sexual abuse (CDC, 2015b). Intimate partners include individuals who are currently in dating, cohabitating, or marital relationships, or those who have been in such relationships in the past. Some of the common terms used to describe IPV are domestic abuse, spouse abuse, domestic violence, gender-based violence, battering, and rape. IPV affects a distressingly high percentage of the population and has physical, psychological, social, and economic consequences (Fig. 9.1).

FIGURE 9.1 Intimate partner violence has significant physical, psychological, social, and economic consequences. An important role of the health care provider is to identify abusive or potentially abusive situations as soon as possible and provide support for the victim.

Because a nurse may be the first health care provider to assess and identify the signs of IPV, a nurse can have a profound impact on a woman’s decision to seek help. Thus, it is important for nurses to be able to identify abuse and aid the victim. IPV can leave significant psychological scars, and a well-trained nurse can have a positive impact on the victim’s mental and emotional health.

Incidence Overall, lifetime, and 1-year estimates for sexual violence, stalking, and IPV are alarmingly high for adult Americans, with IPV alone affecting more than 12 million people each year. On average, 20 persons per minute are victims of rape, physical violence, or stalking by an intimate partner in the United States. Women are disproportionately affected. The estimated cost of violence in the United States exceeds $70 billion each year. Each year, IPV results in an estimated 2,500 deaths and 3 million injuries among women (CDC, 2015c). Women are at risk for violence at nearly every stage of their lives. Old, young, beautiful, unattractive, married, single—no woman is completely safe from the risk of IPV. Current or former husbands or lovers kill over half of the murdered women in the United States. IPV against women causes more serious injuries and deaths than automobile accidents, rapes, and muggings combined. IPV is expensive. The medical cost of IPV approaches $4.4 trillion each year globally to pay for medical and surgical care, counseling, child care, burden on the justice system, incarceration, attorney fees, and loss of work productivity (Lomborg, 2015). IPV is pervasive and crosses all boundaries of sexual orientation, race, and class. The intimidation of another person through abusive acts and words is not a gender issue. Violence within these relationships may go unreported for fear of harassment or ridicule. The medical community’s efforts to address IPV have often neglected members of the lesbian, gay, bisexual, and transgender (LGBT) population. Heterosexual women are primarily targeted for IPV screening and intervention despite the similar prevalence of IPV in LGBT individuals and its detrimental health effects (Cannon & Buttell, 2015). Perhaps because of the multiple barriers that confront LGBT abuse victims and the invisibility of the problem in the context of IPV services, the role of the nurse as their advocate is all the more critical. Little is known about the national prevalence of IPV, sexual violence, and stalking among the LGBT community in the United States. Research documents that rates of IPV among LGBT individuals are equal to or greater than rates observed among heterosexual individuals. Risk factors are also similar to those documented among heterosexual individuals, in addition to help-seeking leaving, and recovery process (Edwards, Sylaska, & Neal, 2015). Current findings seem to also indicate some disparities in perceptions of what constitutes abuse among

same and opposite sex couples (Russell & Chapleau, 2015). The Violence against Women Act has recently been renewed. It now includes coverage of same-sex partners—a big sign that attitudes are changing and improving for gays seeking shelters and help. As individuals and society come to realize same-sex partner violence as an existing problem, there is hope.

Background Until the mid-1970s, our society tended to legitimize a man’s power and control over a woman. The United States legal and judicial systems considered intervention into family disputes wrong and a violation of the family’s right to privacy. IPV was often tolerated and even socially acceptable. Fortunately, attitudes and laws have changed to protect women and punish abusers. In Healthy People 2020, there are 13 measurable violence prevention objectives displayed in the Healthy People 2020 table that follows. In addition to the 13 objectives listed, there are seven developmental objectives that focus on preventing sexual violence across the lifespan and preventing the different forms of partner violence including physical and sexual violence, emotional abuse, and stalking by a current or former partner.

Characteristics of Intimate Partner Violence Although more research is needed in this area, studies have found certain risk factors for IPV in men. These risk factors can be divided into four different categories: individual factors, relationship factors, community factors, and societal factors. Specific risk factors within each category are listed in Table 9.1.

HEALTHY PEOPLE 2020 • 9.1 Violence Prevention Objectives

Generation-to-Generation Continuum of Violence Violence is a learned behavior that, without intervention, is self-perpetuating. It is a cyclical health problem. The long-term effects of violence on victims and children can be profound. Children who witness one parent abuse another are more likely to become delinquents or batterers themselves because they see abuse as an integral part of a close relationship. Thus, an abusive relationship between father and mother can perpetuate future abusive relationships. Violence in childhood and adolescence is linked to the child’s perception of the family as a hostile environment and of violence against women as a corrective measure, and insults, swearing, and humiliation by their partner is acceptable (Song et al., 2015). If one considers violence against children and spouses, the psychological consequences are huge, stemming from the paradox of the victim being abused by a member of the family with whom he or she expects to have a supportive, loving, and respectful relationship. Research has found that children who witness IPV are at risk for developing psychiatric disorders, post-traumatic stress disorder (PTSD), developmental problems, school failure, violence against others, and low self-esteem (Cater et al., 2015). Childhood maltreatment is a major health problem that is associated with a wide range of physical conditions and leads to high rates of psychiatric morbidity and social problems in adulthood. Consequences of violence extend far beyond the physical and mental suffering of victims and their families and have an impact on schools, neighborhoods, businesses, and the legal and health care systems. Women who were physically or sexually abused as children have an increased risk of victimization and fear of crime, poor general health, and in addition experience adverse mental health conditions such as depression, anxiety, and low self-esteem as adults (Barrios et al., 2015). TABLE 9.1 COMMON MYTHS AND FACTS ABOUT VIOLENCE

In many cases when a parent is abused, the children are abused as well. Approximately one in eight children is abused annually in the United States. The lifetime economic cost to society of childhood maltreatment is estimated to be $124 billion dollars (Jackson & Deye, 2015). Young children who live with family violence represent a disempowered group. Developmentally, young children have relatively limited verbal skills and emotional literacy. In addition, the environment becomes one of secrecy and intimidation, as well as reduced emotional availability from the child’s main caretaker. Taken together, these factors severely restrict these young children’s capacity and opportunity to make their voices and needs heard (Jackson & Deye, 2015). Exposure to violence has a negative impact on children’s physical, emotional, and cognitive well-being.

The cycle continues into another generation through learned responses and violent acting out. Although there are always exceptions, most children deprived of their basic physical, psychological, and spiritual needs do not develop healthy personalities. They grow up with feelings of fear, behavioral problems, substance abuse, relationship difficulties, inadequacy, anxiety, anger, hostility, guilt, and rage. They often lack coping skills, blame others, demonstrate poor impulse control, have early delinquent behavior, and generally struggle with authority (Huang et al., 2015). Unless this cycle is broken, more than half become abusers themselves (CDC, 2015e).

The Cycle of Violence In an abusive relationship, the cycle of violence comprises three distinct phases: the tension-building phase, the acute battering phase, and the honeymoon phase (Lawrence, 2015). The cyclical behavior begins with a time of tension-building arguments, progresses to violence, and settles into a making-up or calm period. This cycle of violence increases in frequency and severity as it is repeated over and over again. The cycle can cover a long or short period of time. The honeymoon phase gradually shortens and eventually disappears altogether. Abuse in relationships typically becomes accelerated and thus more dangerous over time. The abuser no longer feels the need to apologize and indulge in a honeymoon phase as the woman becomes increasingly disempowered in the relationship. PHASE 1: TENSION BUILDING During the first—and usually the longest—phase of the cycle, tension escalates between the couple. Excessive drinking, jealousy, or other factors might lead to name-calling, hostility, and friction. The woman might sense that her partner is reacting to her more negatively, that he is on edge and reacts heatedly to any trivial frustration. A woman often will accept her partner’s building anger as legitimately directed toward her. She internalizes what she perceives as her responsibility to keep the situation from exploding. In her mind, if she does her job well, he remains calm. But if she fails, the resulting violence is her fault. PHASE 2: ACUTE BATTERING The second phase of the cycle is the explosion of violence. The batterer loses control both physically and emotionally. This is when the victim may be

assaulted or murdered. After a battering episode, most victims consider themselves lucky that the abuse was not worse, no matter how severe their injuries. They often deny the seriousness of their injuries and refuse to seek medical treatment. PHASE 3: HONEYMOON The third phase of the cycle is a period of calm, loving, and contrite behavior on the part of the batterer. He may be genuinely sorry for the pain he caused his partner. He attempts to make up for his brutal behavior and believes he can control himself and never hurt the woman he loves. The victim wants to believe that her partner really can change. She feels responsible, at least in part, for causing the incident, and she feels responsible for her partner’s well-being (Box 9.1).

BOX 9.1 CYCLE OF VIOLENCE (FEMALE VICTIM AND MALE ABUSER) • Phase 1—Tension building: Verbal or minor battery occurs. Almost any subject, such as housekeeping or money, may trigger the buildup of tension. There is a breakdown of communication. The victim attempts to calm the abuser. Victim feels like “walking on egg shells” around the abuser. • Phase 2—Acute battering: Characterized by uncontrollable discharge of tension. Violence is rarely triggered by the victim’s behavior: she is battered no matter what her response. The start of the battering episode is unpredictable and beyond the victim’s control. • Phase 3—Reconciliation (honeymoon)/calm phase: First, the abuser is ashamed of his behavior. The batterer tries to minimize the abuse and blame it on the partner. The batterer becomes loving, kind, and apologetic and expresses guilt. Then the abuser works on making the victim feel responsible. This loving behavior strengthens the bond between partners and will probably convince the victim, once again, that leaving the relationship is not necessary. Adapted from Domestic Violence Organization.(2015b) Cycle of violence. Retrieved from http://www.domesticviolence.org/cycle-of-violence/; Domestic Violence Roundtable.(2015). The cycle of domestic violence. Retrieved from http://www.domesticviolenceroundtable.org/domestic-violencecycle.html; and National Stress Clinic.(2015). Domestic abuse: Understanding and breaking the cycle of violence. Retrieved from http://www.nationalstressclinic.com/domestic-abuse-understanding-andbreaking-the-cycle-of-violence/

Types of Abuse Abusers may use whatever it takes to control a situation—from emotional abuse and humiliation to physical assault. Victims often tolerate emotional, physical, financial, and sexual abuse. Many remain in abusive relationships because they believe they deserve the abuse.

Emotional Abuse Emotional abuse includes: • Promising, swearing, or threatening to hit the victim • Forcing the victim to perform degrading or humiliating acts • Threatening to harm children, pets, or close friends • Humiliating the woman by name-calling and insults • Threatening to leave her and the children • Isolation from family and friends • Destroying valued possessions • Controlling the victim’s every move

Physical Abuse Physical abuse includes: • Hitting or grabbing the victim so hard that it leaves marks • Throwing things at the victim • Slapping, spitting at, biting, burning, pushing, choking, or shoving the victim • Kicking or punching the victim, or slamming her against things • Attacking the victim with a knife, gun, rope, or electrical cord • Controlling access to health care for injury

Financial Abuse Financial abuse includes: • Preventing the woman from getting a job

• Sabotaging a current job • Controlling how all money is spent • Failing to contribute financially

Sexual Abuse Sexual abuse includes: • Forcing the woman to have vaginal, oral, or anal intercourse against her will • Biting the victim’s breasts or genitals • Shoving objects into the victim’s vagina or anus • Forcing the woman to do something sexual that she finds degrading or humiliating • Forcing the victim to perform sexual acts on other people or animals

Myths and Facts About Intimate Partner Violence Table 9.2 lists many of the myths about IPV. Health care providers should take steps to dispel these myths.

Abuse Profiles Victims Ironically, victims rarely describe themselves as abused. In battered woman syndrome, the woman has experienced deliberate and repeated physical or sexual assault by an intimate partner. She is terrified and feels trapped, helpless, and alone. She reacts to any expression of anger or threat by avoidance and withdrawal behavior. Some women believe that the abuse is caused by a personality flaw or inadequacy in themselves (e.g., inability to keep the man happy). These feelings of failure are reinforced and exploited by their partners. After being told repeatedly that they are “bad,” some women begin to believe it. Many victims were abused as children and may have poor self-esteem, poor health, PTSD, depression, insomnia, low education achievement, or a history of suicide attempts, injury, or drug and alcohol abuse (Barrios et al., 2015).

Abusers Abusers come from all walks of life and often feel insecure, powerless, and helpless; feelings that are not in line with the macho image they would like to project. The abuser expresses his feelings of inadequacy through violence or aggression toward others (Lawson, 2015). Violence typically occurs at home and is usually directed toward the man’s intimate partner or the children who live there. Abusers refuse to share power and choose violence to control their victims. They often exhibit childlike aggression or antisocial behaviors. They may fail to accept responsibility or blame others for their own problems. They might also have a history of substance abuse problems, trouble with the justice system, few close relationships, being sensitive to criticism, having a tendency to hold grudges, involved in power struggles, emotionally dysregulated, lacking in insight, prone to feeling misunderstood, mistreated, or victimized, mental illness, arrests, troubled relationships, obsessive jealousy, controlling behaviors, generally violent behavior, erratic employment history, and financial problems (Lawson, 2015).

Violence Against Pregnant Women Many think of pregnancy as a time of celebration and planning for the unborn child’s future, but in a troubled relationship it can be a time of escalating violence. The strongest predictor of abuse during pregnancy is prior abuse. Violence against pregnant women seems to be more prevalent than diseases routinely investigated during prenatal care, such as preeclampsia and diabetes (Lévesque & Chamberland, 2015). For women who have been abused before, beatings and violence during pregnancy are “business as usual” for them. Women are at a higher risk for violence during pregnancy. Recent research findings indicate that having children does not protect women from IPV. On the contrary, the IPV appears to last longer if women have children, and this also seems to be the case even after the partnership has come to an end (Mauri et al., 2015). Pregnant women are vulnerable during this time, and abusers can take advantage of it. An estimated 325, 000 pregnant women are abused by their partners each year (CDC, 2015a). Abuse during pregnancy poses special risks and dynamics. Various factors may lead to battering during pregnancy, including: • Inability of the couple to cope with the stressors of pregnancy • Young age at time of pregnancy • Having less than a high school education for both partners • Unemployment for either or both in partnership • Violence in the family of origin • Cohabitation and single marital status • Sexual proprietariness on the part of the male partner • Heavy drinking by partner • Resentment toward the interference of the growing fetus and change in the woman’s shape • Doubts about paternity or the expectant mother’s fidelity during pregnancy • Perception that the baby will be a competitor • Outside attention the pregnancy brings to the woman • Unwanted pregnancy

• The woman’s new interest in herself and her unborn baby • Insecurity and jealousy about the pregnancy and the responsibilities it brings • Financial burden related to expense of pregnancy and loss of income • Stress of role transition from adult man to becoming the father of a child • Physical and emotional changes of pregnancy that make the woman vulnerable • Previous isolation from family and friends that limit the couple’s support system TABLE 9.2 COMMON MYTHS AND FACTS ABOUT RAPE

Abuse during pregnancy threatens the well-being of the mother and fetus.

Physical violence may involve injuries to the head, face, neck, thorax, breasts, and abdomen. The mental health consequences are also significant. Several studies have confirmed the relationship between abuse and poor mental health, especially depression and PTSD; poor quality of life; increased distress, fearfulness, anxiousness, and stressfulness; and increased use of tobacco, alcohol, and/or illicit drugs (Lawson, 2015). For the pregnant woman, many of these conditions most often manifest during the postpartum period.

Take Note! Frequently the fear of harm to her unborn child will motivate a woman to escape an abusive relationship. Women assaulted during pregnancy are at risk for: • Injuries to themselves and the fetus • Depression • Panic disorder • Fetal and maternal deaths • Chronic anxiety • Miscarriage • Stillbirth • Poor nutrition • Insomnia • Placental abruption • Uterine rupture • Excessive weight gain or loss • Smoking and substance abuse • Delayed or no prenatal care • Preterm labor • Higher rate of surgical births • Chorioamnionitis

• Vaginitis • Sexually transmitted infections (STIs) • Urinary tract infections • Premature and low-birth-weight infants (AWHONN, 2015) Signs of abuse can emerge during pregnancy and may include poor attendance at prenatal visits, unrealistic fears, weight fluctuations, difficulty with pelvic examinations, and nonadherence to treatment. See Evidence-Based Practice 9.1 for an intervention utilized for pregnant women experiencing IPV. Uncovering abuse in pregnant women requires a consistent and direct approach to every client by the nurse. Multiple assessments may enhance reporting by enabling the nurse to establish trust and rapport with the woman and identify changes in her behavior. Once abuse is discovered in a pregnant woman, interventions should include safety assessment, emotional support, counseling, referral to community services, and ongoing prenatal care to avoid adverse health outcomes (Hewitt, 2015).

EVIDENCE-BASED PRACTICE 9.1 EFFECTIVENESS OF HOME VISITING IN REDUCING PARTNER VIOLENCE FOR FAMILIES EXPERIENCING ABUSE: A SYSTEMATIC REVIEW

STUDY IPV against women is a major, global societal problem with tremendous health consequences both for mother and child. Home visiting interventions by nurses for families at risk of abuse seem promising in decreasing IVP. In this systematic review, the effectiveness of home visiting was assessed as an intervention to reduce IPV experienced by mothers.

Findings A systematic review was conducted of 1,258 articles; nineteen of them met the inclusion criteria and were examined in detail. Sixteen reported lower rates of physical assault with home visits by nurses and three studies showed no significant reduction of IPV. This systematic review found that home visiting interventions that support abused women during their pregnancy and beyond to stop IPV seem to be effective in reducing the incidence of IPV. However, it is not known whether these results are effective in long-term.

Nursing Implications By nurses making home visits, a trusting relationship can be established between the client and nurse. By addressing factors that may increase the risk of IPV in general, such as stress as well as other contributing factors, IPV can be reduced and the cycle of violence can be broken. A major benefit of homevisiting interventions is that they succeed in reaching high-risk young pregnant women, who are notoriously hard to reach for regular prenatal services during a vulnerable stage in their lives. Nurses can see the home environment and can detect risk factors and plan interventions to address them. Adapted from Prosman, G. J., Wong, S. H., van der Wouden, J. C., & Lagro-Janssen, A. L. (2015). Effectiveness of home visiting in reducing partner violence for families experiencing abuse: A systematic review. Family Practice, 32(3), 247–256. (Online: 5/6/15).

Violence Against Older Women IPV affects women of all ages, but often the literature focuses on women in the childbearing years, ignoring the problems of aging women who experience abuse. Elder mistreatment (i.e., abuse and neglect) is defined as intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder. All 50 states have laws requiring health care providers to report elder or vulnerable person abuse. Estimates suggest that 500,000 to 2 million cases of elder abuse and neglect occur annually in the United States. It is estimated that one in ten older adults experience abuse, but only one in five to as little as one in twentyfour are reported. Research suggests that female elders are abused at a higher rate than males and that the older one is, the more likely one is to be abused. Elder abuse is expected to increase as the population ages (Wang et al., 2015). Types of abuse experienced by the older woman may include physical abuse, neglect, emotional abuse, sexual abuse, and financial/exploitation abuse (National Center on Elder Abuse, 2015). Although an injury may bring the older woman into the health care system, the physical and emotional sequelae of IPV may be more subtle and may include depression, insomnia, chronic pain, difficulty trusting others, low self-esteem, thoughts of suicide, substance abuse, anger issues, atypical chest pain, or other kinds of somatic symptoms. Research suggests that older women usually have endured long-term abuse, have developed unhealthy strategies to cope (substance abuse, keeping the family together at all cost, and physical/mental health consequences), and shoulder blame from their adult children, yet have developed empowerment from within to be able to cope with the abuse (Policastro & Finn, 2015). Accurate detection and assessment of abuse in older women are essential duties of all nurses. Nurses have frequent contact with older victims of abuse, providing them the opportunity to play a significant role in detecting, reporting, and intervening in such cases. As part of a thorough screening, nurses should determine what the client has done to attempt to resolve the abuse and the effectiveness of those strategies. Actions taken by the client, prior to revealing her abuse issue to the nurse, might have included passive acceptance, calling law enforcement, counseling, or other measures. In addition, taking time to establish rapport with older women builds a sense of trust, safety, and openness. Nurses

must listen carefully and nonjudgmentally. Judging or criticizing the victim for her decisions might lead to the impression that she deserves the abuse or that she is to blame. Finally, nurses should attempt to stay current in their knowledge of referral resources to assist the older woman experiencing abuse. Some of these resources may be housing, transportation, medical services, employment, social services, and local support groups. A coordinated and comprehensive response to IPV is essential to reduce its sequelae.

Nursing Management of Intimate Partner Violence Victims Nurses encounter thousands of abuse victims each year in their practice settings, but many victims slip through the cracks. As universal violence assessment has increased in recent years, nurses need to be aware of not only how to screen for violence, but how to respond in a way that is helpful, sincere, nonjudgmental, and legally adequate. This will require nurses to move beyond a description of violence toward a response that is action-oriented and evidence-based, which includes safety planning and referrals. There are many things that nurses can do to help victims. Early recognition and intervention can significantly reduce the morbidity and mortality associated with IPV. To stop the cycle of violence, nurses need to know how to assess for and identify IPV and implement appropriate actions.

Assessment Routine screening for IPV is the first way to detect abuse. The nurse should build rapport by listening, showing an interest in the concerns of the woman, and creating an atmosphere of openness. Communicating support through a nonjudgmental attitude and telling the woman that no one deserves to be abused are first steps toward establishing trust and rapport. Rather than overlooking abused women as “chronic complainers,” astute nurses need to be vigilant for subtle clues of abuse. Learning how to assess for abuse is critical. Some basic assessment guidelines follow. SCREEN FOR ABUSE DURING EVERY HEALTH CARE VISIT Screening for violence takes only a few minutes and can have an enormously positive effect on the outcome for the abused woman. Any woman could be a victim; no single sign marks a woman as an abuse victim, but the following clues may be helpful: • Injuries—Bruises on their chest and abdomen, scars from blunt trauma, minor lacerations, or weapon wounds on the face, head, and neck • Injury sequelae—Headaches, hearing loss from ruptured ear drums, joint pain, sinus infections, teeth marks, clumps of hair missing, dental trauma, pelvic

pain, and breast or genital injuries • Reported history of injury that is not consistent with the actual presenting problem • Mental health problems—Depression, anxiety, substance abuse, eating disorders, suicidal ideation or suicide attempts, anger toward health care provider, and PTSD • Frequent tranquilizer or sedative use • Delay in seeking medical attention and patterns of repeated injury • Bruises to the upper arm, neck and face, abdomen, or breasts • Comments about emotional or physical abuse of “a friend” • STIs or pelvic inflammatory disease • Appears nervous, ashamed, or evasive when asked questions • Frequent health care visits for chronic, stress-related disorders such as chest pain, headaches, back or pelvic pain, insomnia, injuries, anxiety, and gastrointestinal disturbances. • Partner’s behavior at the health care visit: appears overly solicitous or overprotective, is unwilling to leave her alone with the health care provider, answers questions for her, and attempts to control the situation (Ghandour, Campbell, & Lloyd, 2015). Dorothy, who you met at the beginning of the chapter, has been frequenting the clinic with vague somatic complaints in recent weeks and admits she is sometimes afraid at home. She tells the nurse her partner doesn’t want her to work, although he is only sporadically employed at low-paying jobs. What cues in her assessment might indicate abuse? What physical signs might the nurse observe? ISOLATE CLIENT IMMEDIATELY FROM FAMILY If abuse is detected, immediately isolate the woman to provide privacy and to prevent potential retaliation from the abuser. Asking about abuse in front of the perpetrator may trigger an abusive episode during the interview or at home. Ways to ensure the woman’s safety would be to take the victim to an area away from the abuser to ask questions. The assessment can take place anywhere that is

private and away from the abuser, for example, x-ray area, ultrasound room, elevator, ladies’ room, or laboratory. If abuse is detected, the nurse can do the following to enhance the nurse–client relationship: • Educate the woman about the connection between the violence and her symptoms. • Help the woman acknowledge what has happened to her and begin to deal with the situation. • Offer her referrals so she can get the help that will allow her to begin to heal. Dorothy returns to the prenatal clinic a month later with anemia, inadequate weight gain, bruises on her face and neck, and second-trimester bleeding. This time she is accompanied by her partner, who stays close to Dorothy. What questions should the nurse ask to assess the situation? Where is the appropriate location to ask these questions? What legal responsibilities does the nurse have concerning her observations? ASK DIRECT OR INDIRECT QUESTIONS ABOUT ABUSE Violence against women is often unseen, unknown, and hidden in families. Questions to screen for abuse should be routine and handled just like any other question. Many nurses feel uncomfortable asking questions of this nature, but broaching the subject is important even if the answer comes later. Opening up the possibility for women to express themselves about their experience of abuse to a nurse sends out a clear message that violence should never be tolerated and not kept hidden; it also conveys the message that nurses care about women’s experiences and want to offer a best practice initial response. Just knowing that someone else knows about the abuse offers a victim some relief and may help her disclose it. Ask difficult questions in an empathetic and nonthreatening manner and remain nonjudgmental in all responses and interactions. Choose the type of question that makes you most comfortable. Direct and indirect questions produce the same results. “Does your partner hit you?” or “Have you ever been or are you now in an abusive relationship?” are direct questions. If that approach feels uncomfortable, try indirect questions: “We see many women with injuries or complaints like yours and often they are being abused. Is that what is happening

to you?” or “Many women in our community experience abuse from their partners. Is anything like that happening in your life?” With either approach, nurses need to maintain a nonjudgmental acceptance of whatever answers the woman offers. The SAVE Model is a screening protocol that nurses can use when assessing women for violence (Box 9.2). ASSESS IMMEDIATE SAFETY It is essential to assist the woman by assessing her safety and the safety of her children. To do this, speak to the woman alone and ask her: • Does she feel safe going home after her meeting with you? • Does she need an immediate place of safety for herself or her children? • Does she have a plan of escape if she becomes at risk for her safety? • Does she need to consider an alternative exit from this building? • Who are the people she could contact for help or support? The Danger Assessment Tool (Box 9.3) helps women and health care providers assess the potential for homicidal behavior in an ongoing abusive relationship. It is based on research that showed several risk factors for abuserelated murders: • Increased frequency or severity of abuse • Presence of firearms • Sexual abuse • Substance abuse • Precipitated by arguments and conflicts • Generally violent behavior outside of the home • Control issues (e.g., daily chores, friends, job, money) • Physical abuse during pregnancy • Suicide threats or attempts (victim or abuser) • Child abuse (Sugg, 2015).

BOX 9.2 SAVE MODEL

SCREEN all of your clients for violence by asking: • Within the last year, have you been physically hurt by someone? • Do you feel you are in control of your life? • Within the last year, has anyone forced you to engage in sexual activities? • Can you talk about your abuse with me now? • In general, how would you describe your present relationship?

ASK direct questions in a nonjudgmental way: • Begin by normalizing the topic to the woman. • Make continuous eye contact with the woman. • Stay calm; avoid emotional reactions to what she tells you. • Never blame the woman, even if she blames herself. • Do not dismiss or minimize what she tells you, even if she does. • Wait for each answer patiently. Do not rush to the next question. • Do not use formal, technical, or medical language. • Avoid using leading questions; be direct and to the point. • Use a nonthreatening, accepting approach.

VALIDATE the client by telling her: • You believe her story. • You do not blame her for what happened. • It is brave of her to tell you this. • Help is available for her. • Talking with you is a hopeful sign and a first big step.

EVALUATE, educate, and refer this client by asking her: • What type of violence was it? • Is she now in any danger? • How is she feeling now? • Does she know that there are consequences to violence? • Is she aware of community resources available to help her? Adapted from USDHHS. (2015c). Screening for domestic violence in health care settings. Office of the Assistant

Secretary

for

Planning

and

Evaluation.

Retrieved

from

http://aspe.hhs.gov/hsp/13/dv/pb_screeningdomestic.cfm; Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN]. (2015). Intimate partner violence. Journal of Obstetric, Gynecologic & Neonatal Nursing, 44(3), 405–408.; and Canadian Domestic Homicide Prevention Initiative. (2015). Risk

assessment,

risk

management

and

safety

planning.

Retrieved

from

http://www.learningtoendabuse.ca/cdhpi/risk-assessment-risk-management-and-safety-planning

DOCUMENT AND REPORT YOUR FINDINGS If the interview reveals a history of abuse, accurate documentation is critical because this evidence may support the woman’s case in court. Documentation must include details about the frequency and severity of abuse; the location, extent, and outcome of injuries; and any treatments or interventions. When documenting, use direct quotes and be very specific: “He choked me.” Describe any visible injuries, and use a body map (outline of a woman’s body) to show where the injuries are. Obtain photos (with informed consent) or document her refusal if the woman declines photos. Pictures or diagrams can be worth a thousand words. Figure 9.2 shows a sample documentation form for IPV. Laws in many states require health care providers to alert the police to any injuries that involve knives, firearms, or other deadly weapons or that present life-threatening emergencies. If assessment reveals suspicion or actual indication of abuse, nurses can explain to the woman that they are required by law to report it.

Nursing Diagnosis

When violence is suspected or validated, the nurse needs to formulate nursing diagnoses based on the completed assessment. Possible nursing diagnoses related to violence against women might include the following: • Deficient knowledge related to understanding the cycle of violence and availability of resources • Anxiety related to threat to self-concept, situational crisis of abuse • Situational low self-esteem related to negative family interactions • Powerlessness related to lifestyle of helplessness • Compromised individual and family coping related to abusive patterns

Interventions The response of nurses to battered women can have a profound effect on their willingness to open up or seek help. Some responses to assist successful communication in these circumstances could include: • Listening—“I hear and understand what you are saying.” Being listened to can be an empowering experience for a woman who has been abused. • Communicating belief-–“That must have been very frightening for you.” • Validating the decision to disclose-–“It must have been difficult for you to talk about this today.” • Emphasizing the unacceptability of this violence—“You don’t deserve to be treated this way.” If abuse is identified, nurses can undertake interventions that can increase the woman’s safety and improve her health. The goal of intervention is to enable the victim to gain control of her life. Provide sensitive, predictable care in an accepting setting. Offer step-by-step explanations of procedures. Provide educational materials about violence. Allow the victim to actively participate in her care and have control over all health care decisions. Pace your nursing interventions and allow the woman to take the lead. Communicate support through a nonjudgmental attitude. Carefully document all of your assessment findings and nursing interventions.

BOX 9.3 DANGER ASSESSMENT TOOL Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. No one can predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for you to see how many of the risk factors apply to your situation. (“He” refers to your husband, partner, exhusband, ex-partner, or whoever is currently physically hurting you). _____1. Has the physical violence increased in severity or frequency over the past year? _____2. Does he own a gun? _____3. Have you left him after living together during the past year? _____4. Is he unemployed? _____5. Has he ever used a weapon against you or threatened you with a lethal weapon? _____6. Does he threaten to kill you? _____7. Has he avoided being arrested for domestic violence? _____8. Do you have a child who is not his? _____9. Has he ever forced you to have sex when you did not wish to do so? ____10. Does he ever try to choke you? ____11. Does he use illegal drugs? By drugs, I mean “uppers” or amphetamines, “meth,” speed, angel dust, cocaine, “crack,” street drugs, or mixtures. ____12. Is he an alcoholic or problem drinker? ____13. Does he control most or all of your daily activities? For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? ____14. Is he violently and constantly jealous of you? (For instance, does he say “If I can’t have you, no one can”). ____15. Have you ever been beaten by him while you were pregnant?

____16. Has he ever threatened or tried to commit suicide? ____17. Does he threaten to harm your children? ____18. Do you believe he is capable of killing you? ____19. Does he follow or spy on you, leave threatening notes or messages on answering machine, destroy your property, or call you when you don’t want him to? ____20. Have you ever threatened or tried to commit suicide? _____ Total “Yes” Answers Thank you. Please talk to your nurse, advocate, or counselor about what the Danger Assessment means in terms of your situation. Source: March of Dimes Danger Assessment questionnaire. From Campbell, J. (1986). Nursing assessment for risk of homicide with battered women. Advances in Nursing Science, 8(4), 36–51.

Concept Mastery Alert Priorities in Intimate Partner Violence Interventions Although it is certainly important that the woman in an abusive situation is safe, it is most important for a woman to regain a sense of control in her life. A lack of control is what prevents a woman from escaping an abusive situation. A public health approach to violence prevention requires input from and coordination across sectors, including health, education, social services, justice, and policy. The goal of public health is to improve the health of the entire community or society. Depending on when in the cycle of violence the nurse encounters the abused woman, goals may fall into three groups: • Primary prevention—aimed at breaking the abuse cycle through community educational initiatives by nurses, physicians, law enforcement, teachers, and clergy. • Secondary prevention—focuses on screening high-risk individuals and dealing with victims and abusers in early stages, with the goal of preventing

progression of abuse. • Tertiary prevention—activities are geared toward helping severely abused women and children recover and become productive members of society and rehabilitating abusers to stop the cycle of violence. These activities are typically long term and expensive.

FIGURE 9.2 Intimate partner violence documentation form. (Reprinted from Home Healthcare Nurse, 17, Cassidy K, How to assess and intervene in domestic violence situations, 644–72, Copyright 1999, with permission from Lippincott Williams & Wilkins.)

A modified tool developed by Holtz and Furniss (1993)—the ABCDES— provides a framework for providing sensitive nursing interventions to abused women (Box 9.4). Specific nursing interventions for the abused woman include educating her about community services, providing emotional support, and offering a safety plan.

BOX 9.4 THE ABCDES OF CARING FOR ABUSED WOMEN • A is reassuring the woman that she is not alone. The isolation by her abuser keeps her from knowing that others are in the same situation and that health care providers can help her. • B is expressing the belief that violence against women is not acceptable in any situation and that it is not her fault. Demonstrate by your actions and words that you believe her disclosure. • C is confidentiality, since the woman might believe that if the abuse is reported, the abuser will retaliate. Interview her in private, without her partner or family members being present. Assure her that you will not release her information without her permission. • D is documentation, which includes the following: • A clear quoted statement about the abuse in the woman’s own words • Accurate descriptions of injuries and the history of them • Information on the first, the worst, and the most recent abusive incident • Photos of the injuries (with the woman’s consent) • E is education about the cycle of violence and that it will escalate: • Educate about abuse and its health effects. • Help her understand that she is not alone. • Offer appropriate community support and referrals. • Display posters and brochures to foster awareness of this public health problem. • S is safety, the most important aspect of the intervention, to ensure that the woman has resources and a plan of action to carry out when she decides to leave. Adapted from Centers for Disease Control & Prevention [CDC]. (2015a). Understanding intimate partner

violence:

Fact

sheet.

Retrieved

from

http://www.cdc.gov/violenceprevention/pub/ipv_factsheet.html; Human Rights Watch. (2015). Abused and

expelled.

Retrieved

from

http://www.hrw.org/sites/default/files/reports/morocco0214_ForUpload.pdf; and Ghandour, R. M., Campbell, J. C., & Lloyd, J. (2015). Screening and counseling for intimate partner violence: A vision for the future. Journal of Women’s Health, 24(1), 57–61.

EDUCATE THE WOMAN ABOUT COMMUNITY SERVICES A wide range of support services are available to meet the needs of victims of violence. Nurses should be prepared to help the woman take advantage of these opportunities. Services will vary by community but might include psychological counseling, legal advice, social services, crisis services, support groups, hotlines, housing, vocational training, and other community-based referrals. Give the woman information about shelters or services even if she initially rejects it. Give the woman the National Domestic Violence hotline number: (800) 799-7233. The Joint Commission on the Accreditation of Hospitals and Health care Organizations (JCAHO), American Medical Association (AMA), American College of Obstetrician Gynecologists (ACOG), and the United States Preventive Services Task Force (USPSTF) all recommend routine IVP screening, counseling, and referrals in all health care agencies (USDHHS, 2015c). PROVIDE EMOTIONAL SUPPORT Providing reassurance and support to a victim of abuse is essential if the violence is to end. The physical, psychological, and emotional effects of IPV on women and their children can be severe and long-lasting. Nurses in all clinical settings can help victims to feel a sense of personal power and provide them with a safe and supportive environment. Appropriate action can help victims to express their thoughts and feelings in constructive ways, manage stress, and move on with their lives. Appropriate interventions are: • Strengthen the woman’s sense of control over her life by: • Teaching coping strategies to manage her stress • Assisting with activities of daily living to improve her lifestyle • Allowing her to make as many decisions as she can • Educating her about the symptoms of PTSD and their basis • Encourage the woman to establish realistic goals for herself by: • Teaching problem-solving skills • Encouraging social activities to connect with other people

• Providing support and allow the woman to grieve for her losses by: • Listening to and clarifying her reactions to the traumatic event • Discussing shock, disbelief, anger, depression, and acceptance • Explain to the woman that: • Abuse is never OK. She didn’t ask for it and she doesn’t deserve it • She is not alone and help is available • Abuse is a crime and she is a victim • Alcohol, drugs, money problems, depression, or jealousy does not cause violence, but these things can give the abuser an excuse for losing control and abusing her • The actions of the abuser are not her fault • Her history of abuse is believed • Making a decision to leave an abusive relationship can be very hard and takes time OFFER A SAFETY PLAN The choice to leave must rest with the victim. Nurses cannot choose a life for the victim; they can only offer choices. Leaving is a process, not an event. Victims may try to leave their abusers as many as seven or eight times before succeeding. Frequently, the final attempt to leave may result in the death of the victim. Women planning to leave an abusive relationship should have a safety plan, if possible (Teaching Guidelines 9.1).

Teaching Guidelines 9.1

SAFETY PLAN FOR LEAVING AN ABUSIVE RELATIONSHIP • When leaving an abusive relationship, take the following items: • Driver’s license or photo ID • Social Security number or green card/work permit

• Birth certificates for you and your children • Phone numbers for social services or women’s shelter • The deed or lease to your home or apartment • Any court papers or orders • A change of clothing for you and your children • Pay stubs, checkbook, credit cards, and cash • Health insurance cards • If you need to leave a domestic violence situation immediately, turn to authorities for assistance in gathering this material. • Develop a “game plan” for leaving and rehearse it. • Don’t use phone cards—they leave a trail to follow. Adapted from Burnett, L. B., & Adler, J. (2015). Domestic violence. eMedicine. Retrieved from http://emedicine.medscape.com/article/805546-overview; Murray, C. E., Horton, G. E., Johnson, C. H., Notestine, L., Garr, B., Pow, A. M., et al. (2015). Domestic violence service providers’ perceptions of safety planning: A focus group study. Journal of Family Violence, 30(3), 381–392; and Chang, J. C. (2015). Domestic violence: Epidemiology and risk factors. Clinical Gynecology (2nd ed., pp. 94–101). Cambridge, UK: Cambridge University Press.

Nurses need to remember that their role is that of a guide, not a savior. A woman will make the best decision she sees fit at that moment in time. A nurse may be her most effective resource in her stress-filled environment. Just allowing the woman to talk may be the most valuable intervention. The impact of the nurse’s presence and support will stay with the woman, no matter what decision she makes.

SEXUAL VIOLENCE Sexual violence is both a public health problem and a human rights violation. Sexual violence includes IPV, human trafficking, incest, FGC, forced prostitution, bondage, exploitation, neglect, infanticide, and sexual assault. It occurs worldwide and affects up to one third of women over a lifetime (BagwellGray, Messing, & Baldwin-White, 2015). Once every 2 minutes, 30 times an hour, 1,871 times a day, girls and women in America are raped. One in five women and 1 in 71 men will be sexually assaulted during their lifetime (Rape, Abuse, & Incest National Network [RAINN], 2015a). Rape has been reported against females from age 6 months to 93 years, but it still remains one of the most underreported violent crimes in the United States. Once every 2 minutes, a woman is sexually assaulted in the United States (RAINN, 2015a). The National Center for Prevention and Control of Sexual Assault estimates that two thirds of sexual assaults will not be reported (CDC, 2015f). Over the course of their lives, women may experience more than one type of violence. Sexual violence can have a variety of devastating short- and long-term effects. Women can experience psychological, physical, and cognitive symptoms that affect them daily. They can include chronic pelvic pain, headaches, backache, STIs, pregnancy, anxiety, denial, fear, withdrawal, sleep disturbances, guilt, nervousness, phobias, substance abuse, depression, sexual dysfunction, and PTSD. Many contemplate suicide (CDC, 2015f). A traumatic experience not only damages a woman’s sense of safety in the world, but it can also reduce her self-esteem and her ability to continue her education, to earn money and be productive, to have children and, if she has children, to nurture and protect them. Overall, sexually assaulted women exhibit lower functioning as adults afterward (MacGregor et al., 2015).

Take Note! Sexual violence has been called a “tragedy of youth.” More than half of all rapes (54%) of women occur before age 18 (Medicine Net, 2015a).

Characteristics of Assailants Assailants, like their victims, come from all walks of life and all ethnic backgrounds; there is no typical profile. More than half are under age 25, and the majority are married and leading “normal” sex lives. Why do men rape? No theory provides a satisfactory explanation. So few assailants are caught and convicted that a clear profile remains elusive. What is known is that many assailants have trouble dealing with the stresses of daily life. Such men become angry and experience feelings of powerlessness. They become jealous easily; do not view women as equals; frequently are hot tempered; have a need to be reassured of their manhood; and do not handle stress in their lives well. They commit a sexual assault as an expression of power and control (Kilmartin, 2015).

Sexual Abuse Sexual abuse occurs when a woman is forced to have sexual contact of any kind (vaginal, oral, or anal) without her consent. Current estimates indicate that one of five girls is sexually abused, and the peak ages of such abuse are from 8 to 12 years of age. At every age in the life span, females are more likely to be sexually abused by father, brother, family member, neighbor, boyfriend, husband, partner, or ex-partner than by a stranger or anonymous assailant. Sexual abuse knows no economic or cultural barriers (de Jong et al., 2015). Marriage does not constitute a tacit agreement for a spouse to inflict one’s demands on the other without permission. Childhood sexual abuse is any type of sexual exploitation that involves a child younger than 18 years old. It might include disrobing, nudity, masturbation, fondling, digital penetration, forced performance of sexual acts on the perpetrator, and intercourse (Dutton, 2015). Childhood sexual abuse has a lifelong impact on its survivors. There is strong evidence that sexual assault in childhood or adolescence is a serious risk factor for mental illness (Brooker & Durmaz, 2015). Women who were sexually abused during childhood are at a heightened risk for repeat abuse. This is because the early abuse lowers their self-esteem and their ability to protect themselves and set firm boundaries. Childhood sexual abuse is a trauma that influences the way victims form relationships, deal with adversity, cope with daily problems, relate to their children and peers, protect their health, and live. See Evidence-Based Practice 9.2 for study regarding childhood sexual abuse. Studies have shown that the more victimization a woman experiences, the more likely it is she will be revictimized (Brenner & Ben-Amitay, 2015). Interventions for sexually abused children or women should include referral for mental health counseling. Follow up for any medical problems (e.g., genitourinary complaints) should be arranged with the child’s or woman’s primary care physician. If the community has an abuse referral center, refer the victim there for follow-up care according to local protocol. The medical consequences of sexual abuse require the prophylaxis and treatment of STIs, emergency contraception, and treatment of any injuries that resulted from the abuse. Victims with post-assault bleeding require an emergent evaluation and may need emergency treatment by a gynecologist for repair of genital injury. The psychosocial aspects of sexual abuse must also be addressed

because appropriate therapeutic follow-up is essential to the victim’s future emotional well-being.

EVIDENCE-BASED PRACTICE 9.2 SIBLING SEXUAL ABUSE: AN EXPLORATORY STUDY OF LONG-TERM CONSEQUENCES FOR SELF-ESTEEM AND COUNSELING CONSIDERATIONS Today, health care providers recognize childhood sexual abuse within the family as a significant and widespread problem with consequences lasting long into adulthood. Despite this progression, the research related to interfamilial incest conducted by researchers has focused primarily on father to daughter incest, largely ignoring the experience of sibling sexual assault, although it is more common than parental incest. Clearly, sibling incest is a pandemic problem that requires more attention from health care providers.

STUDY This study addresses experiencing sibling sexual abuse as a child and how it inversely affects the level of self-esteem in adulthood. One hundred college students were used as the sample size; 67% were female and 33% were male with a diverse cultural representation. The age of the students ranged from 20 to 59 years old. A survey with two sections was used. The first section addressed recollection of the prevalence and severity of sibling abuse; the second section of the survey addressed self-esteem using the Rosenberg SelfEsteem Scale. Reliability and validity of this tool reflected a Cronbach’s alpha coefficient of 0.82.

Findings This study supported the likelihood that sibling sexual abuse could be the most common form of child sexual abuse in the United States. In spite of the apparent prevalence of this, it is disturbing how little has been done to address the complexity surrounding this form of abuse. Both survivors and offenders of sibling sexual abuse experience the lasting impact of the abuse as they become adults in their social interactions, school, work, and family life. In addition to a low self-esteem, other mental health issues experienced include symptoms of PTSD, anxiety disorders, depression, eating disorders, angry outbursts, self-injury, somatic complaints, and suicidal ideation. Many engage in at-risk behaviors such as unprotected sex, self-medication with drugs and alcohol, and dating violence. Clearly, ignoring the problem of sibling sexual abuse has a negative effect on a sense of well-being as these children become adults.

Nursing Implications One of the most important aspects is to establish trust with these clients and create a safe environment. An important role for nurses is in primary prevention of sibling sexual abuse through educating parents. When parents understand how to promote positive parent–child relationships and sibling interactions, the risk of abuse in the entire family tends to be reduced. Nurses can take a lead role through promotion of structured parent education programs within their communities and referrals to national networks such as Family Support America. Adopted from Morrill, M. (2014). Sibling sexual abuse: An exploratory study of long term consequences for self-esteem and counseling considerations. Journal of Family Violence, 29(2), 205– 213.

Incest Incest is defined as sexual activity between persons so closely related that marriage between them is legally or culturally prohibited (Dorland’s Medical Dictionary, 2015). The exact incidence of child sexual victimization is unknown. Such sexual abuse is not only a crime but also a symptom of acute and irreversible family dysfunction. Childhood incest abuse involves any kind of sexual exploitation between a child and another person that violates the social taboos of family roles; children cannot yet understand these activities and cannot give informed consent. Adult women with a history of incest exhibit a clinical syndrome that includes low self-esteem, difficulty with intimate relationships, sexual dysfunction, flashbacks and nightmares, repeated victimization, as well as suicidality, depressive symptomatology, eating disorders, and substance abuse (Harkins, 2015). Survivors of incest are often tricked, coerced, or manipulated. All adults appear to be powerful to children. Perpetrators might threaten victims so that they are afraid to disclose the abuse or might tell them the abuse is their fault. Often these threats serve to silence victims. Incestuous relationships in the home endanger not only the child’s intellectual and moral development, but also the health of the child. Many children do not ask for help because they do not want to expose their “secret.” For this reason, just the tip of the iceberg is statistically visible: serious injuries, internal damage, STIs, or pregnancy. Incest can have serious long-term effects on its victims, which may include eating disorders, sexual problems in adult life, difficulty in interpersonal relationships, anxiety, PTSD, intense guilt and shame, low selfesteem, depression, and self-destructive behavior (National Center for Victims of Crime [NCVC], 2015a). Whether an incest victim endured an isolated incident of abuse or ongoing assaults over an extended period, recovery can be painful and difficult. The recovery process begins with admission of abuse and the recognition that help and services are needed. Resources for incest victims include books, self-help groups, workshops, therapy programs, and possibly legal remedies. In addition to listening to and believing incest victims, nurses need to search for ways to prevent future generations from enduring such abuse and from continuing the cycle of abuse in their own family and relationships. Nurses have the ability and the responsibility to function within an interdisciplinary system responsible for the assessment and ongoing treatment of incestuous families. Nurses can fulfill

their roles as advocates for children, while at the same time adding necessary referrals to social services and legal authorities. Forming this partnership with the social service and judicial communities will help protect the child from future abuse and ensure the child a safe environment in which to grow and develop.

Take Note! Childhood sexual abuse is a trauma that can affect every aspect of the victim’s life.

Rape Rape is an expression of violence, not a sexual act. Rape distorts one of the most intimate forms of human interaction. It is not an act of lust or an overzealous release of passion: it is a violent, aggressive assault on the victim’s body and integrity. Those who rape do so for a number of reasons, but they basically involve the motives of anger, power, eroticized cruelty, and opportunistic mating (Keygnaert, Vettenburg, & Temmerman, 2015). Rape is a legal rather than a medical term. It denotes penile penetration of the vagina, mouth, or rectum of the female or male without consent. It may or may not include the use of a weapon. Statutory rape is sexual activity between an adult and a person under the age of 18 and is considered to have occurred even if the underage person was willing (RAINN, 2015b). Nine out of every 10 rape victims are female (Alexander et al., 2014). Enforcement of laws, education, and community empowerment are all needed to prevent rape.

Consider This

At 53 years old, I stood and looked at myself in the mirror. The image staring back at me was one of a frightened, middle-aged, cowardly woman hiding her past. I had been sexually abused by my father for many years as a child and never told anyone. My mother knew of the abuse but felt helpless to make it stop. I married right out of high school to escape and felt I lived a “happy normal life” with my husband and three children. My children have left home and live away, and my husband recently died of a sudden heart attack. I am now experiencing dreams and thoughts about my past abuse and feeling afraid again. Thoughts: This woman suppressed her abusive past for most of her life and now her painful experience has surfaced. What can be done to reach out to her at this point? Did her health care providers miss the “red flags” that are common to women with a history of childhood sexual abuse all those years?

TABLE 9.3 FOUR PHASES OF RAPE RECOVERY

Many people believe that rape usually occurs on a dark night when a stranger assaults a provocatively dressed, promiscuous woman. They believe that rapists are sex-starved people seeking sexual gratification. Rape myths are destructive beliefs about sexual aggression (i.e., its scope, causes, context, and consequences) that serve to deny, downplay, or justify sexually aggressive behavior that men commit against women. A rape victim’s recovery is frequently complicated by the public’s failure to believe the victim and restore justice

(Klaus, Buczkowski, & Wiktorska, 2015). Rape myths serve to blame victims and exonerate perpetrators. Such myths and the facts are presented in Table 9.3.

Acquaintance Rape In acquaintance rape, someone is forced to have sex by a person he or she knows. Rape by a coworker, a teacher, a husband’s friend, or a boss is considered acquaintance rape. Date rape, an assault that occurs within a dating relationship or marriage without consent of one of the participants, is a form of acquaintance rape. Acquaintance and date rapes commonly occur on college campuses. One in four college women has been raped—that is, has been forced, physically or verbally, actively or implicitly, to engage in sexual activity (Wilson & Miller, 2015). These forms of rape are physically and emotionally devastating for the victims. Research has indicated that the survivors of acquaintance rape report similar levels of depression, anxiety, complications in subsequent relationships, and difficulty attaining prerape levels of sexual satisfaction to those reported by survivors of stranger rape. Acquaintance rape remains a controversial topic because there is lack of agreement on the definition of consent. Despite the violation and reality of physical and emotional trauma, victims of acquaintance assault often do not identify their experience as sexual assault. Instead of focusing on the violation of the sexual assault, victims of acquaintance rape often blame themselves for the assault (RAINN, 2015c). Although acquaintance rape and date rape do not always involve drugs, a rapist might use alcohol or other drugs to sedate his victim. In 1996, the federal government passed a law making it a felony to give an unsuspecting person a “date rape drug” with the intent of raping him or her. Even with penalties of large fines and up to 20 years in prison, the use of date rape drugs is growing (USDHHS, 2015a). Date rape drugs are also known as “club drugs” because they are often used at dance clubs, fraternity parties, and all-night raves. The most common is rohypnol (also known as “roofies,” “forget pills,” “mind erasers,” or the “drop drug”). It comes in the form of a liquid or pill that quickly dissolves in liquid with no odor, taste, or color. This drug is 10 times as strong as diazepam (Valium). The effects can be felt within 30 minutes and produces memory loss for up to 8 hours. Gamma hydroxybutyrate (GHB; called “liquid ecstasy” or “easy lay”) produces euphoria, an out-of-body high, sleepiness, increased sex drive, and memory loss. GHB takes effects in about 15 minutes

and can last 3 to 4 hours. It comes in a white powder or liquid and may cause unconsciousness, depression, and coma. The third date rape drug, ketamine (known as “Special K,” “vitamin K,” or “super acid”), and acts on the central nervous system very quickly to separate perception and sensation. Combining ketamine with other drugs can be fatal. Date rape drugs can be very dangerous, and women can protect themselves against them in a variety of ways (Teaching Guidelines 9.2).

Teaching Guidelines 9.2

PROTECTING YOURSELF AGAINST DATE RAPE DRUGS • Avoid parties where alcohol is being served. • Never leave a drink of any kind unattended. • Don’t accept a drink from someone else. • Accept drinks from a bartender or in a closed container only. • If a drink is left unattended, pour it out, don’t drink it. • Don’t drink anything that tastes or smells strange. • Don’t drink from a punch bowl or a keg. • If you think someone drugged you, call 911.

Rape Recovery Rape survivors take a long time to heal from their traumatic experience. Some women never heal and never get professional counseling, but most can cope. Rape is viewed as a situational crisis that the survivor is unprepared to handle because it is an unforeseen event. Survivors typically go through four phases of recovery following rape (Table 9.4). A significant proportion of women who are raped also experience symptoms of PTSD. PTSD develops when an event outside the range of normal human experience occurs that produces marked distress in the person. Symptoms of PTSD are divided into three groups: 1. Intrusion (reexperiencing the trauma, including nightmares, flashbacks,

recurrent thoughts) 2. Avoidance (avoiding trauma-related stimuli, social withdrawal, emotional numbing) 3. Hyperarousal (increased emotional arousal, exaggerated startle response, irritability) Not every traumatized female develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident, but occasionally may only emerge years later. They must last more than a month to be considered PTSD. The condition varies from person to person. Some women recover within months, while others have symptoms for much longer. In some people, the condition becomes chronic (Darnell et al., 2015; Friedman, 2015).

Nursing Management of Rape Victims Health care providers, along with sexual assault nurse examiners (SANE), can make a difference in the lives of survivors by understanding the facts, the effects this violence can have on mental and physical health, where to find information for themselves and their clients, and how to properly care for a survivor. A SANE is a registered nurse specially trained to conduct sexual assault evidentiary examinations for rape victims. In addition to the collection of forensic evidence, they also provide access to crisis intervention, STI testing, and emergency contraception (International Association of Forensic Nurses, 2015). TABLE 9.4 RISK FACTORS FOR INTIMATE PARTNER VIOLENCE IN MEN

Research has found that rape survivors undergo a profound and complex trauma. Exposure therapy has been used to help victims confront their traumarelated memories, feelings, and stimuli that evoke fear and anxiety (Nacasch, Rachamim, & Foa, 2015). The survivor should be provided with a safe and comfortable environment for a forensic examination. Nursing care of the rape survivor should focus on providing supportive care, collecting and documenting evidence, assessing for STIs, preventing pregnancy, and assessing for PTSD. Once initial treatment and evidence collection have been completed, follow-up care should include counseling, medical treatment, and crisis intervention. There is mounting evidence that early intervention and immediate counseling speed a rape survivor’s recovery. By early intervention, it means interventions that implemented in the initials hours, days, or weeks after the traumatic event (Bryant, 2015). Nursing Care Plan 9.1 highlights a sample plan of care for a victim of rape.

NURSING CARE PLAN 9.1 Overview of the Woman Who is a Victim of Rape Lucia, a 20-year-old college junior, was admitted to the emergency room after police found her when a passerby called 911 to report an assault. She stated, “I was raped a few hours ago while I was walking home through the park.” Assessment reveals the following: numerous cuts and bruises of varying sizes on her face, arms, and legs; lip swollen and cut; right eye swollen and bruised; jacket and shirt ripped and bloodied; hair matted with grass and debris; vital signs within acceptable parameters; client tearful, clutching her clothing, and trembling; perineal bruising and tearing. NURSING DIAGNOSIS: Rape-trauma syndrome related to report of recent sexual assault Outcome Identification and Evaluation Client will demonstrate adequate coping skills related to effects of rape as evidenced by her ability to discuss the event, verbalize her feelings and fears, and exhibit appropriate actions to return to her precrisis level of functioning. Interventions: Promoting Adequate Coping Skills • Stay with the client to promote feelings of safety. • Explain the procedures to be completed based on facility’s policy to help alleviate client’s fear of the unknown. • Assist with physical examination for specimen collection to obtain evidence for legal proceedings. • Administer prophylactic medication as ordered to prevent pregnancy and STIs. • Provide care to wounds as ordered to prevent infection. • Assist client with hygiene measures as necessary to promote self-esteem. • Allow client to describe the events as much as possible to encourage ventilation of feelings about the incident; engage in active listening and offer nonjudgmental support to facilitate coping and demonstrate understanding of the client’s situation and feelings. • Help the client identify positive coping skills and personal strengths used in

the past to aid in effective decision making. • Assist client in developing additional coping strategies and teach client relaxation techniques to help deal with the current crisis and anxiety. • Contact the rape counselor in the facility to help the client deal with the crisis. • Arrange for follow-up visit with rape counselor to provide continued care and to promote continuity of care. • Encourage the client to contact a close friend, partner, or family member to accompany her home to provide support. • Provide the client with the telephone number of a counseling service or community support groups to help her cope and obtain ongoing support. • Provide written instructions related to follow-up appointments, care, and testing to ensure adequate understanding.

Take Note! Many rape survivors seek treatment in the hospital emergency department if no rape crisis center is available. Unfortunately, many emergency department doctors and nurses have little training in how to treat rape survivors or in collecting evidence. To make matters worse, if they have to wait for hours in public waiting rooms, survivors may leave the hospital, never to receive treatment or supply the evidence needed to arrest and convict their assailants. PROVIDING SUPPORTIVE CARE Establishing a therapeutic and trusting relationship will help the survivor describe her experience. Take the woman to a secure, isolated area away from family, friends, and other clients and staff so she can be open and honest when asked about the assault. Provide a change of clothes, access to a shower and toiletries, and a private waiting area for family and friends. COLLECTING AND DOCUMENTING EVIDENCE The victim should be instructed to bring all clothing, especially undergarments, worn at the time of the assault to the medical facility. The victim should not shower or bathe before presenting for care. Typically a specially trained nurse will collect the evidence from the victim.

ASSESSING FOR SEXUALLY TRANSMITTED INFECTIONS As part of the assessment, a pelvic examination will be done to collect vaginal secretions to rule out any STIs. This examination is very emotionally stressful for most women and should be carried out very gently and sensitively. PREVENTING PREGNANCY An essential element in the care of rape survivors involves offering them pregnancy prevention. After unprotected intercourse, including rape, pregnancy can be prevented by using an emergency contraceptive pill, sometimes called postcoital contraception. Emergency contraceptive pills involve high doses of the same oral contraceptives that millions of women take every day. The emergency regimen consists of one dose taken within 72 to 120 hours of the unprotected intercourse. Emergency contraception works by preventing ovulation, fertilization, or implantation. It does not disrupt an established pregnancy and should not be confused with mifepristone (RU-486), a drug approved by the Food and Drug Administration for abortion in the first 49 days of gestation. Emergency contraception is most effective if it is taken within 12 hours of the rape; it becomes less effective with every 12 hours of delay thereafter. ASSESSING FOR POSTTRAUMATIC STRESS DISORDER Nurses can begin to assess the extent to which a survivor is suffering from PTSD by asking the following questions: • To assess the presence of intrusive thoughts: • Do upsetting thoughts and nightmares of the trauma bother you? • Do you feel as though you are actually reliving the trauma? • Does it upset you to be exposed to anything that reminds you of that event? • To assess the presence of avoidance reactions: • Do you find yourself trying to avoid thinking about the trauma? • Do you stay away from situations that remind you of the event? • Do you have trouble recalling exactly what happened? • Do you feel numb emotionally? • To assess the presence of physical symptoms:

• Are you having trouble sleeping? • Have you felt irritable or experienced outbursts of anger? • Do you have heart palpitations and sweating? • Do you have muscle aches and pains all over? (NCVC, 2015b). With a growing body of knowledge about rape-related PTSD, help is available through most rape crisis and trauma centers. Support groups have been established where survivors can meet regularly to share experiences to help relieve the symptoms of PTSD. For some survivors, medication prescribed along with therapy is the best combination to relieve the pain. Just as in the treatment of any other illness, at the first opportunity, the woman should be encouraged to talk about the traumatic experience. This ventilating provides a chance to receive needed support and comfort, as well as an opportunity to begin making sense of the experience. To diminish symptoms of PTSD, survivors must work on two fronts: coming to terms with the past and alleviating stress in the present (Bryant, 2015). In order to have a better understanding of the aftermath of criminal victimization such as sexual assault, nurses must begin to accept the reality that crime is random, senseless, and can happen to anyone regardless of the precautions that are taken to prevent it. Nurses must also understand that a victim’s life is turned upside down when he or she becomes a victim of crime. In order to help victims to trust society again and regain a sense of balance and self-worth, nurses must educate all those who come in contact with victims and survivors to be sensitive to their needs.

Female Genital Cutting FGC, also referred to as female genital mutilation (FGM) or female circumcision, is defined as a procedure involving any injury of the external female genitalia for cultural or nontherapeutic reasons. It confers severe health consequences for girls and women. The international community views this practice as a human rights violation (Gayle & Rymer, 2015). It is the surgical removal of a portion or portions of the genitalia of female infants, girls, and women, including the clitoris (type I), clitoris and labia minora (type II), and clitoris, labia minora, labia majora, and then suturing of the remaining tissue, known as fibulation, to leave only a small opening for urination, menstruation, intercourse, and childbirth (type III). There is a type IV, which encompasses all other mutilations of the female genital area such as pricking, piercing, cutting, cauterizing, and scraping of the vaginal tissue, incisions to the clitoris and vagina, and burning, scarring, or cauterizing of tissue with the aim of tightening or narrowing the vagina (Nour, 2015). FGC is a worldwide practice that affects millions of women and girls. According to the World Health Organization (WHO) (2015b) and UNICEF, 140 million women are victims of FGC with about 130 million girls between infancy and age 15 undergoing FGC every year. Countries where this is practiced include 30 African countries and parts of the Middle East and Asia. Prevalence in countries such as Sudan and Egypt has been estimated as high as 99% (Johnsdotter, 2015). The exact origins of FGC are not known. Although FGC may be interwoven into the culture, it is not mandated by any religion. This practice predates both Islam and Christianity (Gruenbaum & Wirtz, 2015). In some cultures, it is associated with feminine beauty and often signifies a rite of passage from childhood to adulthood. Female cutting is performed to decrease a woman’s sexual desires and to ensure her chastity until marriage and receipt of a dowry from the prospective groom (Farage et al., 2015). Ultimately, the reality of being ostracized by the community and the possibility of being ineligible to marry create enormous social pressure to have FGC carried out, pressure that outweighs the known physical and emotional damage of this practice (Nour, 2015). Complications vary, depending on the type of cutting and the way it was performed. It is frequently performed without anesthesia under nonsterile conditions. Cutting tools can be anything from razors blades to knives to pieces

of glass or tin can lids. Complications can include infertility, dysmenorrhea, dyspareunia, sexual dysfunction, infection, hemorrhage after the procedure, vaginal stenosis, chronic vaginitis, pelvic inflammatory disease, chronic urinary tract infections, incontinence, genital fistulas, recurrent abscesses, transmission of HIV and hepatitis during the procedure, severe pain and shock after the procedure, difficulty walking or using stairs due to severe scarring, urinary retention, inability to experience orgasm, and difficulty in giving birth. Longterm complications related to FGC include chronic pain, dyspareunia, and difficult childbirth. The most common long-term complication is the formation of inclusion clitoral dermoid cysts and labial fusion. These become large as a grapefruit and can lead to difficulty in walking, sitting and can cause psychological distress from the deformity. The psychological effects range from eating disorders, insomnia, depression, PTSD, and negative effects on the women’s self-esteem and identity (Creighton, 2015). As immigration to the United States increases, nurses are increasingly likely to encounter women affected by FGC and its complications. The psychological pressure and trauma of being torn between two cultures and feeling different may lie heavily on the women in a new setting where FGC is foreign and banned. Nurses need updated education regarding women with FGC so that appropriate care for this population can be provided for this very sensitive health care problem. Well-informed nurses are the best tool for providing culturally sensitive care to this population. Nurses are in a unique position to contact and educate women who have been cut or are at risk for mutilation. To advocate for these women, a thorough understanding of the practice of FGC, its cultural overtones, religious implications, and psychosocial effects is needed.

Take Note! From a Western perspective, FGC is hard to comprehend. Because it is not talked about openly in communities that practice it, women who have undergone it accept it without question and assume it is done to all girls (Gruenbaum & Wirtz, 2015).

Background Reasons for performing the ritual reflect the ideology and cultural values of each

community that practices it. Some consider it a rite of passage into womanhood; others use it as a means of preserving virginity until marriage. In cultures where it is practiced, it is an important part of culturally defined gender identity. In any case, all the reasons are cultural and traditional and are not rooted in any religious texts (Research Action and Information Network for the Bodily Integrity of Women [RAINBO], 2015). Since FGC has no health benefits and often leaves women with lifelong physical and emotional trauma, there is a human rights justification to end the practice. International pressure to end FGC has been mounting since 1997, when the WHO, UNICEF, and UNFPA issued a joint statement to call on governments to ban the practice (Borsand et al., 2015). Box 9.5 lists types of FGC procedures.

BOX 9.5 FOUR MAJOR TYPES OF FEMALE GENITAL MUTILATION PROCEDURES Type I: Excision of the prepuce with excision of part or the entire clitoris Type II: Excision of the clitoris and part or all of the labia minora Type III (Infibulation): Excision of all or part of the external genitalia and stitching/narrowing of the vaginal opening Type IV: Pricking, piercing, or incision of the clitoris or labia • Stretching of the clitoris and/or labia • Cauterizing by burning the clitoris and surrounding tissues • Scraping or cutting the vaginal orifice • Introduction of a corrosive substance into the vagina • Placing herbs into the vagina to narrow it Adapted from World Health Organization [WHO]. (2015b). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/print.html; Nour, N. M. (2015). Female genital cutting: Impact on women’s health. Seminars in Reproductive Medicine, 33(1), 41–46; and Research Action and Information Network for the Bodily Integrity of Women [RAINBO]. (2015). Caring for women

with

circumcision:

Fact

sheet

for

physicians.

Retrieved

from

http://www.rainbo.org/factsheet.html.

Nursing Management of Female Genital Cutting Client Because of increasing migration, nurses throughout the world are increasingly exposed to women who have experienced these procedures and thus need to know about its impact on women’s reproductive health. Helping women who have had an FGC procedure requires good communication skills and often an interpreter, since many may not speak English. As nurses, we are educated to provide comprehensive, culturally sensitive care regardless of our client’s circumstances. Nurses must keep in mind that FGC is considered normal in many cultures and to not have it done would be unthinkable. Nurses have the opportunity to educate clients by providing accurate information and positive

health care experiences. Make sure that you are comfortable with your own feelings about this practice before dealing with clients. Some guidelines are as follows: • Let the client know you are concerned and interested and want to help. • Speak clearly and slowly, using simple, accurate terms. • Use the term or name for this practice that the recipient uses, not “female genital cutting.” • Use pictures and diagrams to help the woman understand what you are saying. • Be patient in allowing the client to answer questions. • Include men in any education, as they are influential in this practice. • Repeat back your understanding of the client’s statements. • Always look and talk directly to the client, not the interpreter. • Place no judgment on the cultural practice. • Maintain respect for older women who have experienced FGC. • Encourage the client to express herself freely. • Maintain strict confidentiality. • Provide culturally attuned care to all women. In short, FGC is a form of violence against women, and it is only through education and empowerment of women that real changes in this practice can be made. Because this practice often defines a woman and becomes a part of her identity, nurses must understand this to be able to assist women who have had this done to them. Only through intense education will the next generation of girls be saved from this practice.

Human Trafficking The United Nations defines human trafficking as the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force, of abduction, of fraud, or deception to achieve the consent of a person having control over another person, for the purpose of exploitation (United Nations Office on Drugs and Crime, 2015). A girl who was just 14 years old was held captive in a tiny trailer room, where she was forced to have sex with as many as 30 men a day. On her nightstand was a teddy bear that reminded her of her childhood in Mexico from where she was abducted and forced into sexual slavery. This scenario describes human trafficking, the enslavement of immigrants for profit in America. Within our borders, thousands of foreign nationals and US citizens, many of them children, are forced or coerced into sex work or various forms of labor every year (Weitzer, 2015). Human trafficking is both a global problem and a domestic problem. The United States is a major receiver of trafficked persons. Human trafficking is a modern form of slavery that affects nearly 1 million people worldwide and approximately 20,000 persons in the United States annually (U.S. Department of State, 2015). Women and children are the primary victims of human trafficking, many in the sex trade as described above and others through forced-labor domestic servitude. Poverty and lack of economic opportunity make women and children potential victims of traffickers associated with international criminal organizations. They are vulnerable to false promises of job opportunities in other countries. Many of those who accept these offers from what appear to be legitimate sources find themselves in situations where their documents are destroyed, they or their families threatened with harm, or they are bonded by a debt that they have no chance of repaying. Trafficking persons is hugely profitable: one estimate places global profits at approximately $35 billion annually. Among illegal enterprises, trafficking is second only to drug dealing and is tied with the illegal arms industry in its ability to generate dollars (Aronowitz & Koning, 2015). The United States is a profitable destination country for traffickers, and these profits contribute to the development of organized criminal enterprises worldwide. According to findings of the Victims of Trafficking and Violence Protection Act of 2000: • Victims are primarily women and children who lack education, employment,

and economic opportunities in their own countries. • Traffickers promise victims employment as nannies, maids, dancers, factory workers, sales clerks, or models in the United States. • Traffickers transport the victims from their counties to unfamiliar destinations away from their support systems. • Once they are here, traffickers coerce them, using rape, torture, starvation, imprisonment, threats, or physical force, into prostitution, pornography, the sex trade, forced labor, or involuntary servitude. These victims are exposed to serious and numerous health risks such as rape; physical injury such as cigarette burns, fractures, bruises; torture; HIV/AIDS; STIs; cervical cancer; violence; hazardous work environments; poor nutrition; and drug and alcohol addiction (Greenbaum et al., 2015). Health care is one of the most pressing needs of these victims, but no comprehensive care is available to undocumented immigrants. Nurses and other health care providers who encounter victims of trafficking often do not realize it, and opportunities to intervene are lost. Although no one sign can demonstrate with certainty when someone is being trafficked, clinicians should be aware of several indicators. It is important to be alert for trafficking victims in any setting and to recognize cues (Box 9.6).

BOX 9.6 IDENTIFYING VICTIMS OF HUMAN TRAFFICKING Look beneath the surface and ask yourself: Is this person… • A female or a child in poor health? • Foreign-born and doesn’t speak English? • Lacking immigration documents? • Giving an inconsistent explanation of injury? • Reluctant to give any information about self, injury, home, or work? • Fearful of authority figure or “sponsor” if present? (“Sponsor” might not leave victim alone with health care provider). • Living with the employer? Sample questions to ask the potential victim of human trafficking: • Can you leave your job or situation if you wish? • Can you come and go as you please? • Have you been threatened if you try to leave? • Has anyone threatened your family with harm if you leave? • What are your working and living conditions? • Do you have to ask permission to go to the bathroom, eat, or sleep? • Is there a lock on your door so you cannot get out? • What brought you to the United States? Are your plans the same now? • Are you free to leave your current work or home situation? • Who has your immigration papers? Why don’t you have them? • Are you paid for the work you do? • Are there times you feel afraid? • How can your situation be changed? Adapted from United Nations Office on Drugs and Crime [UNODC]. (2015). Human trafficking. Retrieved

from http://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html;

Sanchez, R., & Stark, S. (2014). The hard truth about human trafficking. Nursing Management, 45(1), 18–23; and Weitzer, R. (2015). Human trafficking and contemporary slavery. Annual Review of Sociology, 41(1). Retrieved from http://www.annualreviews.org/doi/abs/10.1146/annurev-soc-073014112506

Nursing interventions in the case of trafficking victims would include the following: • Building trust is the number-one priority • Take the time to listen and develop rapport • Screen in a private place to ensure confidentiality and safety • Reassure the potential victim • One-on-one interactions are ideal • Specifically ask about the client’s safety • Offer reworded stories • Stay calm and on an even keel • Understand the risk these victims are taking by disclosing their plight • Always document your suspicion in your notes, at the very least • Call the human trafficking hotline for guidance: 1-866-US-TIPLINE Human trafficking is a violation of human rights. Few crimes are more repugnant than the sex trafficking of helpless and innocent victims. Nurses are one of the few groups of professionals likely to interact with trafficked victims while they are still in captivity. They have the opportunity to screen, identify, intervene, and rescue these victims. If you suspect a trafficking situation, notify local law enforcement and a regional social service organization that has experience in dealing with trafficking victims. It is imperative to reach out to these victims and stop the cycle of abuse by following through on your suspicions. Nurses can also reach out within their communities to bring about awareness through community education to human trafficking to uncover the hard truth about it to our nation’s blind eyes.

SUMMARY The causes of violence against women are complex. Previously, violence against women was largely invisible, natural, and trivial. Many laughed at the notion that intimate or community violence against women should be seen as a human rights violation. Raising awareness and developing evidence-based programs, practices, and policies to prevent IPV and sexual assault are essential in stopping violent behavior before it starts. Many women will experience some type of violence in their lives, and it can have a debilitating effect on their health and future relationships. Nurses have the skills, professional experience, and perspective to be an important part of comprehensive violence prevention efforts in communities. Violence is a preventable public health problem if multiple sectors understand patterns of violence and implement prevention strategies to reduce it (Copelon, 2015). Violence frequently leaves a “legacy of pain” to future generations. Nurses can empower women and encourage them to move forward and take control of their lives. When women live in peace and security, free from violence, they have an enormous potential to contribute to their own communities and to the national and global society. Nurses can play an important role in working toward the creation of a violence-free community, but they must first become informed. Nurses must insist that health care agencies that employ them accept this responsibility and work together to reach out to those being abused. The time is ripe for nurses to act and ensure serious inroads are made in improving the health and well-being of all women across the globe. Violence against women is not normal, legal, or acceptable and it should never be tolerated or justified. It can and must be stopped by the entire world community. Early education and prevention provide the best hope for creating healthy futures and fostering a global society without violence. KEY CONCEPTS Violence against women is a major public health and social problem because it violates a woman’s very being and causes numerous mental and physical health sequelae. Every woman has the potential to become a victim of violence.

Several Healthy People 2020 objectives focus on reducing the rate of physical assaults and the number of rapes and attempted rapes. Abuse may be mental, physical, or sexual in nature or a combination of all of these. The cycle of violence includes three phases: tension building, acute battering, and honeymoon. Many women experience PTSD after being sexually assaulted. PTSD can inhibit a survivor from adapting or coping in a healthy manner. Pregnancy can precipitate violence toward the woman or escalate it. FGC is practiced worldwide and nurses in the United States need to become knowledgeable about it and place no judgment on this cultural practice. Human trafficking is a violation against human rights, and nurses who suspect it should report it to stop the cycle of abuse against young children and women. The nurse’s role in dealing with survivors of violence is to establish rapport; open up lines of communication; apply the nursing process to assess and screen all clients in all settings; and implement and intervene as appropriate.

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from http://tahoesafealliance.org/for-lgbqtia/lgbtqiamyths/ The Advocacy Center. (2015). The path toward recovery for survivors of sexual violence. Retrieved from http://advocacycenter.syr.edu/students/path-of-recovery/ The Christian Broadcasting Network [CBN]. (2015). 12 traits of an abuser. Retrieved from http://www.cbn.com/family/marriage/petherbridge_abusertraits.aspx United Nations Office on Drugs and Crime [UNODC]. (2015). Human trafficking. Retrieved from http://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html U.S. Department of Health and Human Services [USDHHS]. (2015a). Date rape drugs fact sheet. National Women’s Health Information Center. Retrieved from http://www.womenshealth.gov/publications/ourpublications/fact-sheet/date-rape-drugs.html U.S. Department of Health and Human Services [USDHHS]. (2015b). Healthy People 2020. Retrieved from http://www.healthypeople.gov/document/HTML/Volume2/15Injury.htm#_Toc490549392 USDHHS. (2015c). Screening for domestic violence in health care settings. Office of the Assistant Secretary for Planning and Evaluation. Retrieved from http://aspe.hhs.gov/hsp/13/dv/pb_screeningdomestic.cfm U.S. Department of State. (2015). What is modern slavery? Retrieved from http://www.state.gov/j/tip/what/index.htm Victims of Trafficking and Violence Protection Act of 2000, Pub. Law No. 106–386 [H.R. 3244]. (2000). Retrieved from http://ojp.gov/vawo/laws/vawo2000/stitle_a.htm. Wang, X. M., Brisbin, S., Loo, T., & Straus, S. (2015). Elder abuse: An approach to identification, assessment and intervention. CMAJ: Canadian Medical Association Journal, 187(8), 575–581. Weitzer, R. (2015). Human trafficking and contemporary slavery. Annual Review of Sociology, 41(1). Retrieved from http://www.annualreviews.org/doi/abs/10.1146/annurev-soc-073014-112506 WELLWVU The Student’s Center of Health. (2015). Rape myths and facts. Retrieved from https://well.wvu.edu/articles/rape_myths_and_facts Wilson, L. C., & Miller, K. E. (2015). Meta-analysis of the prevalence of unacknowledged rape. Trauma, Violence, & Abuse, pii: 1524838015576391.. Women Against Violence Against Women [WAVAW]. (2015). Rape myths. Retrieved from http://www.wavaw.ca/mythbusting/rape-myths/ World Health Organization [WHO]. (2015a). Violence against women fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs239/en/ World Health Organization [WHO]. (2015b). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/print.html

Chapter WORKSHEET

MULTIPLE-CHOICE QUESTIONS 1. The primary goal of intervention in working with abused women is to: a. Set up an appointment with a mental health counselor for the victim b. Convince them to set up a safety plan to use when they leave c. Help them develop courage and financial support to leave the abuser d. Empower them and improve their self-esteem to regain control of their lives 2. The first phase of the abuse cycle is characterized by: a. The woman provoking the abuser to bring about battering b. Tension building and verbal or minor battery c. A honeymoon period that lulls the victim into forgetting d. An acute episode of physical battering 3. Women recovering from abusive relationships need to learn ways to improve their: a. Educational level by getting a college degree b. Earning power so they can move to a better neighborhood c. Self-esteem and communication skills to increase assertiveness d. Relationship skills so they will be better prepared to deal with their partners 4. Which of the following statements might empower abuse victims to take action? a. “You deserve better than this.” b. “Your children deserve to grow up in a two-parent family.” c. “Try to figure out what you do to trigger his abuse and stop it.” d. “Give your partner more time to come to his senses about this.” 5. If a woman thinks she is being stalked when driving, a good safety measure is to: a. Drive to a local police or fire department b. Take short cuts through back streets to lose them c. Wave a handgun to intimidate them

d. Roll down her window and confront them 6. Nurses play an important role in screening and assessment of any client abuse/violence. Which of the following statements is correct? a. Most clients are extremely reluctant to come forth with private matters b. Any intimate partner violence questions should be asked in the presence of both partners c. To invite disclosure, assure the woman that you won’t document her statements d. The best statement to make to the abused victim is: “You don’t deserve this.” 7. What should the nurse do if a victim of intimate partner violence chooses not to disclose information about her abusive relationship during your interview? a. Confront the victim with the physical evidence and telltale signs of abuse b. Contact family members to tell you about their abusive relationship c. Call the local police department to inquire about domestic disturbance calls d. Respect the client’s right of self-determination and provide her with resources

CRITICAL THINKING EXERCISE 1. Mrs. Boggs has three children under the age of 5 and is 6 months pregnant with her fourth child. She has made repeated unscheduled visits to your clinic with vague somatic complaints regarding the children as well as herself, but has missed several scheduled prenatal appointments. On occasion she has worn sunglasses to cover bruises around her eyes. As a nurse you sense there is something else bothering her, but she doesn’t seem to want to discuss it with you. She appears sad and the children cling to her. a. Outline your conversation when you broach the subject of abuse with Mrs. Boggs. b. What is your role as a nurse in caring for a family in which you suspect abuse is occurring? c. What ethical/legal considerations are important in planning care for this family?

STUDY ACTIVITIES 1. Visit the BellaOnline Domestic Violence website for victims of violence. Discuss what you discovered on this site and your reactions to it. 2. Research the statistics about violence against women in your state. Are law enforcement and community interventions reducing the incidence of sexual assault and intimate partner violence? 3. Attend a dorm orientation at a local college to hear about measures in place to protect women’s safety on campus. Find out the number of sexual assaults reported and what strategies the college uses to reduce this number. 4. Volunteer to spend a weekend evening at the local sheriff’s department 911 hotline desk to observe the number and nature of calls received reporting domestic violence. Interview the dispatch operator about the frequency and trends of these calls. 5. Identify three community resources that could be useful to a victim of violence. Identify their sources of funding and the services they provide.

BRINGING IT ALL TOGETHER: CASE STUDY A 23-year-old pregnant female presents to the public health maternity clinic for the third time in a month with many vague complaints including insomnia, diffuse body aches and pains, poor appetite, fatigue, and constipation. This is her first pregnancy, and it was unplanned. Her recent OB examination findings and laboratory survey are within normal limits. Her past medical history is remarkable for anxiety and depression. According to the client, she does not drink or smoke. She does not work outside of the home.

ASSESSMENT On physical examination, the nurse notes a well-dressed, pleasant, but anxious young female. Her husband of a year usually accompanies her to the office visits, but is absent today. She tends to avoid eye contact with the nurse when asked questions about her symptoms. Her vital signs and fetal heart rate are all within the normal range. On further examination, the nurse notices several

bruises on her upper arms and thighs. When questioned about these marks, the client looks away. Go to to find questions to consider about this case.

unit three Pregnancy

10 Fetal Development and Genetics

KEY TERMS allele blastocyst embryonic stage fertilization fetal stage genes genetic counseling genetics genome genomics genotype

heterozygous homozygous karyotype monosomies morula mutation phenotype placenta polyploidy preembryonic stage teratogen trisomies trophoblast umbilical cord zona pellucida zygote

Learning Objectives Upon completion of the chapter, you will be able to: 1. Characterize the process of fertilization, implantation, and cell differentiation. 2. Examine the functions of the placenta, umbilical cord, and amniotic fluid. 3. Outline normal fetal development from conception through birth. 4. Compare the various inheritance patterns, including nontraditional patterns of inheritance. 5. Analyze examples of ethical and legal issues surrounding genetic testing. 6. Research the role of the nurse in genetic counseling and genetic-related activities. Robert and Kate Shafer have just received the good news that Kate’s pregnancy test was positive. It had been a long and anxious 3 years of trying to start a family. Although both are elated about the prospect of becoming parents, they are also concerned about the possibility of a genetic problem because Kate is 41 years old. What might be their first step in looking into their genetic concern? As a nurse, what might raise concerns for you?

Words of Wisdom Being a nurse without awe is like food without spice. Nurses only have to witness the miracle of life to find their lost awe.

INTRODUCTION Human reproduction is one of the most intimate spheres of an individual’s life. Conception occurs when a healthy ovum from the woman is released from the ovary, passes into an open Fallopian tube, and starts its journey downward. Sperm from the male is deposited into the vagina and swims approximately 7 in to meet the ovum at the outermost portion of the Fallopian tube, the area where fertilization takes place. This process occurs in about an hour (Sermon & Viville, 2014). When one spermatozoon penetrates the ovum’s thick outer membrane, a new living cell is formed that is unlike the cells of either parent. Soon, the two nuclei will fuse, bringing together about 25,000 genes to guide human development. Nurses caring for the childbearing family need to have a basic understanding of conception and prenatal development so they can identify problems or variations and can initiate appropriate interventions should any problems occur. This chapter presents an overview of fetal development, beginning with conception. It also discusses hereditary influences on fetal development and the nurse’s role in genetic counseling.

FETAL DEVELOPMENT Fetal development during pregnancy is measured in number of weeks after fertilization. An average human pregnancy lasts for about 280 days or 40 weeks from the date of the last menstrual period (LMP). Traditionally, it has been calculated as 10 lunar months, or, in terms of the modern calendar, 9 months. Fertilization of the egg by the sperm, however, usually occurs (considering an average menstrual cycle of 28 days) 14 days after the last period. Thus, the average actual duration of a human pregnancy (gestation period) is 280 days − 14 days = 266 days. The three stages of fetal development during pregnancy are the: 1. Preembryonic stage—fertilization through the second week 2. Embryonic stage—end of the second week through the eighth week 3. Fetal stage—end of the eighth week until birth Fetal circulation is a significant aspect of fetal development that spans all three stages.

Preembryonic Stage The preembryonic stage begins with fertilization, also called conception. Fertilization is the union of ovum and sperm, which is the starting point of pregnancy. Development during this stage takes place in an organized fashion that is cephalocaudal, proximal to distal, and general to specific. Fertilization typically occurs around 2 weeks after the last normal menstrual period in a 28day cycle (Mader & Windelspecht, 2015). Fertilization requires a timely interaction between the release of the mature ovum at ovulation and the ejaculation of enough healthy, mobile sperm to survive the hostile vaginal environment through which they must travel to meet the ovum. All things considered, the act of conception is difficult at best. To say merely that it occurs when the sperm unites with the ovum is overly simple because this union requires an intricate interplay between hormonal preparation and overcoming an overwhelming number of natural barriers. A human being is truly an amazing outcome of this elaborate process. Prior to fertilization, the ovum and the spermatozoon undergo the process of meiosis. The primary oocyte completes its first meiotic division before ovulation. The secondary oocyte begins its second meiotic division just before ovulation. Primary and secondary spermatocytes undergo meiotic division while still in the testes. Gametogenesis is the process by which gametes (ovum or sperm cells) are produced to initiate the development of a new individual. The gametes must have a haploid number of chromosomes (a single set, i.e., 23) so when they come together to form the zygote, the normal human diploid number of chromosomes (combination of two sets, i.e., 46) is established (Fig. 10.1). This smaller number of chromosome number found in eggs and sperm is vital because these gametes combine to form a new individual with 46 chromosomes. Although each milliliter of ejaculated semen contains more than 200 million sperm, only one is able to enter the ovum to fertilize it. All others are blocked by the clear protein layer called the zona pellucida. The zona pellucida disappears in about 5 days. Once the sperm reaches the plasma membrane, the ovum resumes meiosis and forms a nucleus with half the number of chromosomes (23). When the nucleus from the ovum and the nucleus of the sperm make contact, they lose their respective nuclear membranes and combine their maternal and paternal chromosomes. Because each nucleus contains a haploid number of chromosomes (23), this union restores the diploid number (46). The

resulting zygote begins the process of a new life. The genetic information from both ovum and sperm establishes the unique physical characteristics of the individual. Sex determination is also determined at fertilization and depends on whether the ovum is fertilized by a Y-bearing sperm or an X-bearing sperm. Approximately 50% of sperms carry the XX chromosome while the other 50% carry XY. An XX zygote will become a female and an XY zygote will become a male (Fig. 10.2). That is why it is scientifically correct to say that the sex of the infant is determined by the father and not by the mother. Fertilization takes place in the outer third of the ampulla of the Fallopian tube. When the ovum is fertilized by the sperm (now called a zygote), a great deal of activity immediately takes place. Mitosis, or cleavage, occurs as the zygote is slowly transported into the uterine cavity by tubal muscular movements (Fig. 10.3). After a series of four cleavages, the 16 cells appear as a solid ball of cells or morula, meaning “little mulberry.” The morula continues to divide and transforms into a blastocyst as it moves further into the uterus. The morula reaches the uterine cavity about 72 hours after fertilization (Mueller, Hassel, & Grealy, 2015).

FIGURE 10.1 The formation of gametes by the process of meiosis is known as gametogenesis. A. Spermatogenesis. One spermatogonium gives rise to four spermatozoa. B. Oogenesis. From each oogonium, one mature ovum and three abortive cells are produced. The chromosomes are reduced to one half the number characteristic for the general body cells of the species. In humans, the number in the body cells is 46, and that in the mature spermatozoon and secondary oocyte is 23.

FIGURE 10.2 Inheritance of gender. Each ovum contains 22 autosomes and an X chromosome. Each spermatozoon (sperm) contains 22 autosomes and either an X chromosome or a Y chromosome. The gender of the zygote is determined at the time of fertilization by the combination of the sex chromosomes of the sperm (either X or Y) and the ovum (X).

FIGURE 10.3 Mitosis of the stoma cells.

FIGURE 10.4 A. Fertilized human egg (zygote) having reached the blastocyst stage. Zygote contains 20 to 30 eggs and a fluid-filled blastocele is beginning to form. B. Implantation. Stylized image showing a frontal view of a uterus with a blastocyst about to implant into endometrium of the uterus. (From LifeART image copyright © 2011 Lippincott Williams & Wilkins. All rights reserved).

Multiple fetuses can also occur at the time of fertilization when more than one ovum is fertilized. Identical twins (also called monozygotic twins) occur when one fertilized egg splits and develops into two (or occasionally more) fetuses. The fetuses usually share one placenta. Identical twins have the same genes, so they generally look alike and are the same sex. Fraternal twins (also called dizygotic twins) develop when two separate eggs are fertilized by two different sperm. Each twin usually has its own placenta. Fraternal twins (like other siblings) share about 50% of their genes, so they can be different sexes. They generally do not look any more alike than brothers or sisters born from different pregnancies. Fraternal twins are more common than identical twins (see Chapter 19 for further details). With additional cell division, the morula divides into specialized cells that will later form fetal structures. Within the morula, an off-center, fluid-filled space appears, transforming it into the hollow ball of cells called a blastocyst (Fig. 10.4). The inner surface of the blastocyst will form the embryo and amnion. The outer layer of cells surrounding the blastocyst cavity is called a trophoblast. Eventually, the trophoblast develops into one of the embryonic membranes, the chorion, and helps to form the placenta. At this time, the developing blastocyst needs more food and oxygen to keep growing. The trophoblast attaches itself to the surface of the endometrium for

further nourishment. Normally, implantation occurs in the upper uterus (fundus), where a rich blood supply is available. This area also contains strong muscular fibers, which clamp down on blood vessels after the placenta separates from the inner wall of the uterus. Additionally, the lining is thickest here so the placenta cannot attach so strongly that it remains attached after birth. The process of attachment and placental formation is termed implantation. From a medical perspective, a pregnancy has not occurred until successful implantation has taken place (Jones & Lopez, 2014). Figure 10.5 shows the process of fertilization and implantation. Concurrent with the development of the trophoblast and implantation, further differentiation of the inner cell mass occurs. Some of the cells become the embryo itself, and others give rise to the membranes that surround and protect it. The three embryonic layers of cells formed are: 1. Ectoderm—forms the central nervous system, special senses, skin, and glands. 2. Mesoderm—forms the skeletal, urinary, circulatory, and reproductive organs. 3. Endoderm—forms the respiratory system, liver, pancreas, and digestive system. These three layers are formed at the same time as the embryonic membranes, and all tissues, organs, and organ systems develop from these three primary germ cell layers (El-Mazny, 2014). Box 10.1 summarizes preembryonic development. Despite the intense and dramatic activities going on internally to create a human life, many women are unaware that pregnancy has begun. Several weeks will pass before even one of the presumptive signs of pregnancy—missing the first menstrual period—will take place.

FIGURE 10.5 Fertilization and tubal transport of the zygote. From fertilization to implantation, the zygote travels through the fallopian tube, experiencing rapid mitotic division (cleavage). During the journey toward the uterus, the zygote evolves through several stages, including morula and blastocyst.

Embryonic Stage The embryonic stage of development begins at day 15 after conception and continues through week 8. Basic structures of all major body organs and the main external features are completed during this time period, including internal organs. Table 10.1 and Figure 10.6 summarize embryonic development.

BOX 10.1 SUMMARY OF PREEMBRYONIC DEVELOPMENT • Fertilization takes place in ampulla of the Fallopian tube. • Union of sperm and ovum forms a zygote (46 chromosomes). • Cleavage cell division continues to form a morula (mass of 16 cells). • The inner cell mass is called a blastocyst, which forms the embryo and amnion. • The outer cell mass is called a trophoblast, which forms the placenta and chorion. • Implantation occurs 7 to 10 days after conception in the endometrium.

The embryonic membranes (Fig. 10.7) begin to form around the time of implantation. The chorion consists of trophoblast cells and a mesodermal lining. The chorion has finger-like projections called chorionic villi on its surface. The amnion originates from the ectoderm germ layer during the early stages of embryonic development. It is a thin protective membrane that contains amniotic fluid. Alongside of the amnion, a yolk sac develops as a second cavity about day 8 or 9 after conception. The yolk sac aids in transferring maternal nutrients and oxygen to the embryo during the second and third weeks of gestation when development of the uteroplacental circulation is under way. As the pregnancy progresses, the yolk sac atrophies and is incorporated into the umbilical cord. As the embryo grows, the amnion expands until it touches the chorion. These two fetal membranes form the fluid-filled amniotic sac, or bag of waters, that protects the floating embryo (Jordan et al., 2014). Amniotic fluid surrounds the embryo and increases in volume as the pregnancy progresses, reaching approximately a liter at term. Amniotic fluid is derived from two sources: fluid transported from the maternal blood across the amnion and fetal urine. Its volume changes constantly as the fetus swallows and voids. Sufficient amounts of amniotic fluid help maintain a constant body temperature for the fetus, permit symmetric growth and development, cushion the fetus from trauma, allow the umbilical cord to be relatively free from

compression, and promote fetal movement to enhance musculoskeletal development. Amniotic fluid is composed of 98% water and 2% organic matter. It is slightly alkaline and contains albumin, urea, uric acid, creatinine, bilirubin, lecithin, sphingomyelin, epithelial cells, vernix, and fine hair called lanugo that floats in it. Amniotic fluid is essential for fetal growth and development, especially fetal lung development. It is dynamic, constantly changing as the fluid moves back and forth across the placental membrane (Zhang & Ducsay, 2014). TABLE 10.1 EMBRYONIC AND FETAL DEVELOPMENT

The volume of amniotic fluid is important in determining fetal well-being. It gradually fluctuates throughout the pregnancy. The rate of change of amniotic fluid volume depends on the gestational age. During the fetal stage, the increase is 10 mL/week, and it increases to 50 to 60 mL/week at 19 to 25 weeks’ gestation. The volume is at a maximum at 34 weeks’ gestation before it undergoes a gradual decrease by term. Alterations in amniotic fluid volume can be associated with problems in the fetus. Too little amniotic fluid (2,000 mL at term), termed hydramnios, is

associated with maternal diabetes, neural tube defects, chromosomal deviations, and malformations of the central nervous system and/or gastrointestinal tract that prevent normal swallowing of amniotic fluid by the fetus (Moore, 2015).

FIGURE 10.6 Embryonic development. A. Four-week embryo. B. Five-week embryo. C. Six-week embryo.

FIGURE 10.7 A. The embryo is floating in amniotic fluid, surrounded by the protective fetal membranes (amnion and chorion). B. Longitudinal sonogram of a pregnant uterus at 11 weeks showing the intrauterine gestational sac (black arrowheads) and the amniotic cavity (AC) filled with amniotic fluid; the fetus is seen

in longitudinal section with the head (H) and coccyx (C) well displayed. The myometrium (MY) of the uterus can be identified. (Figure B is courtesy of L Scoutt).

While the placenta is developing (end of the second week), the umbilical cord is also formed from the amnion. It is the lifeline from the mother to the growing embryo. It contains one large vein and two small arteries. Wharton’s jelly (a specialized connective tissue) surrounds these three blood vessels in the umbilical cord to prevent compression, which would cut off fetal blood and nutrient supply. At term, the average umbilical cord is 22-in long and about an inch wide (King et al., 2015). The precursor cells of the placenta—the trophoblasts—first appear 4 days after fertilization as the outer layer of cells of the blastocyst. These early blastocyst trophoblasts differentiate into all of the cells that form the placenta. When fully developed, the placenta serves as the interface between the mother and the developing fetus. Most commonly, the placenta develops at the uterine fundus. As early as 3 days after conception, the trophoblasts make human chorionic gonadotropin (hCG), a hormone that ensures that the endometrium will be receptive to the implanting embryo. During the next few weeks, the placenta begins to make hormones that control the basic physiology of the mother in such a way that the fetus is supplied with the nutrients and oxygen needed for growth. The placenta is the least understood human organ and arguably one of the most important. The placenta also protects the fetus from immune attack by the mother, removes waste products from the fetus, induces the mother to bring more food to the placenta and, near the time of delivery, produces hormones that ready fetal organs for life outside the uterus. The placenta allows the developing fetus to rely on the maternal circulation to fulfill its bioenergetics needs while growing undisturbed in the protected environment of the uterus (Fisher, 2015). Theoretically, at no time during pregnancy does the mother’s blood mix with fetal blood because there is no direct contact between their bloods; layers of fetal tissue always separate the maternal blood and the fetal blood. These fetal tissues are called the placental barrier. Materials can be interchanged only through diffusion. The maternal uterine arteries deliver the nutrients to the placenta, which in turn provides nutrients to the developing fetus; the mother’s uterine veins carry fetal waste products away. The structure of the placenta is usually completed by week 12. During its transient existence, it performs actions that are later taken on by diverse separate organs, including the lungs, liver, gut, kidneys

and endocrine glands. The placenta is not only a transfer organ but a hormone factory as well. Placental hormones have profound effects on maternal metabolism, initially building up her energy reserves and then releasing these to support fetal growth in later pregnancy and lactation postnatally. Several hormones are produced that are necessary for normal pregnancy: • hCG: preserves the corpus luteum and its progesterone production so that the endometrial lining of the uterus is maintained; this is the basis for pregnancy tests. • Human placental lactogen (hPL) or human chorionic somatomammotropin (hCS): modulates fetal and maternal metabolism, participates in the development of maternal breasts for lactation, and decreases maternal glucose utilization, which increases glucose availability to the fetus. • Estrogen (estriol): causes enlargement of a woman’s breasts, uterus, and external genitalia; stimulates myometrial contractility. • Progesterone (progestin): maintains the endometrium, decreases the contractility of the uterus, stimulates maternal metabolism and breast development, provides nourishment for the early conceptus (the products of conception after fertilization in the early stages of growth and differentiation). • Relaxin:acts synergistically with progesterone to maintain pregnancy, causes relaxation of the pelvic ligaments, and softens the cervix in preparation for birth (Freemark, 2015). The placenta acts as a pass-through between the mother and fetus, not a barrier. Almost everything the mother ingests (food, alcohol, and drugs) passes through to the developing conceptus. This is why it is so important to advise pregnant women not to use unprescribed drugs, alcohol, and tobacco, because they can be harmful to the conceptus. Although prescription drug use is common during pregnancy, the human teratogenic risks are undetermined for more than 90% of drug treatments approved in the United States during the past decades (Dutta, 2015). During the embryonic stage, the conceptus grows rapidly as all organs and structures are forming. During this critical period of differentiation the growing embryo is most susceptible to damage from external sources, including teratogens (substances that cause birth defects, such as alcohol and drugs), infections (such as rubella or cytomegalovirus), radiation, and nutritional

deficiencies.

Teratogens A teratogen is any substance, organism, physical agent, or deficiency state present during gestation that is capable of inducing abnormal postnatal structure or function by interfering with normal embryonic and fetal development (March of Dimes, 2015a). Teratogens are substances that may produce physical or functional defects in the human embryo or fetus after the pregnant woman has been exposed to that substance. Teratogens affect the fetus or embryo in a number of ways, causing physical deformities, problems in the behavioral or emotional development of the child, and decreased intellectual quotient (IQ) in the child. Additionally, teratogens may also affect pregnancies and cause complications such as preterm labors and spontaneous abortions. Susceptibility to teratogenic agents is dependent on the timing of the exposure and the developmental stage of the embryo or fetus. Teratogens are classified into four types: physical agents, metabolic conditions, infection, and drugs/chemical agents. Selected harmful teratogens to newborns include: • Ionizing radiation—leads to abnormal brain development, mental retardation, and leukemia in children. • Organic mercury—leads to damage of neural system, mental retardation, behavioral and cognitive problems, and blindness in an infant. • Lead exposure—can cause spontaneous abortions, delayed fetal development, increased risk of fetal death, or abnormal mental or physical development of a child. • Toxoplasma—leads to spontaneous abortion, or stillbirth, underdeveloped fetal brain, blindness, and seizures. • Syphilis bacteria—cause fetal death, spontaneous abortion, liver and spleen enlargement, and congenital syphilis. • Rubella virus—leads to abnormal brain development in the fetus. • Cytomegalovirus—leads to underdevelopment of the fetal brain, blindness, deafness, jaundice, liver and spleen dysfunction. • Varicella zoster—leads to underdeveloped limbs, brain or eye malformations. • Herpes virus—causes fetal death, microcephaly, herpetic pneumonia, and

meningoencephalitis. • Maternal conditions—obesity, diabetes, hypothyroidism, hyperthyroidism, and phenylketonuria (PKU). • Drugs—thalidomide (limb malformations), alcohol (fetal alcohol syndrome), angiotensin-converting enzyme (ACE) inhibitors (antihypertensive agents) (prematurity, intrauterine growth restriction [IUGR]); cocaine (abruptio placenta, prematurity, microcephaly); and tetracycline (yellow-brown teeth discoloration); (Dutta, 2015).

Fetal Stage The average pregnancy lasts 280 days from the first day of the LMP. The fetal stage is the time from the end of the eighth week until birth. It is the longest period of prenatal development. During this stage, the embryo is mature enough to be called a fetus. Although all major systems are present in their basic form, dramatic growth and refinement of all organ systems take place during the fetal period (Table 10.1). Figure 10.8 depicts a 12- to 15-week-old fetus.

FIGURE 10.8 Fetal development: 12- to 15-week fetus.

Fetal Circulation Fetal circulation differs from adult circulation due to the presence of certain vessels and shunts. These shunts will close after birth and most of these vessels will be seen as remnants in the adult circulation. The function of these shunts is to direct oxygen-rich venous blood to the systemic circulation and to ensure that oxygen-depleted venous blood bypasses the underdeveloped pulmonary circulation. The lungs finish their development after birth. Prior to this, the lung’s function is taken over by the placenta, which therefore becomes the oxygen-transfer organ during fetal life (Finnemore & Groves, 2015). The circulation through the fetus during uterine life differs from that of a child or an adult. In the extrauterine world, oxygenation occurs in the lungs and oxygenated blood returns via the pulmonary veins to the left side of the heart to be ejected by the left ventricle into the systemic circulation. In contrast, fetal circulation oxygenation occurs in the placenta, and the fetal lungs are nonfunctional as far as the transfer of oxygen and carbon dioxide is concerned. For oxygenated blood derived from the placenta to reach the fetus’ systemic circulation, it has to travel through a series of shunts to accomplish this. Thus, fetal circulation involves the circulation of blood from the placenta to and through the fetus, and back to the placenta. A properly functioning fetal circulation system is essential to sustain the fetus. Before it develops, nutrients and oxygen diffuse through the extraembryonic coelom and the yolk sac from the placenta. As the embryo grows, its nutrient needs increase and the amount of tissue easily reached by diffusion increases. Thus, the circulation must develop quickly and accurately (Jones & Lopez, 2014). Three shunts also are present during fetal life: 1. Ductus venosus—connects the umbilical vein to the inferior vena cava. 2. Ductus arteriosus—connects the main pulmonary artery to the aorta. 3. Foramen ovale—anatomic opening between the right and left atrium.

Take Note! Fetal circulation functions to carry highly oxygenated blood to vital areas (e.g., heart, brain) while first shunting it away from less important ones (e.g., lungs,

liver). The placenta essentially takes over the functions of the lungs and liver during fetal life. As a result, large volumes of oxygenated blood are not needed. The blood with the highest oxygen content is delivered to the fetal heart, head, neck, and upper limbs, while the blood with the lowest oxygen content is shunted toward the placenta. The oxygenated blood is carried from the placenta to the fetus via the umbilical vein. About half of this blood passes through the hepatic capillaries and the rest flows through the ductus venosus into the inferior vena cava. Blood from the vena cava is mostly deflected through the foramen ovale into the left atrium, then to the left ventricle, into the ascending aorta, and on to the head and upper body. This allows the fetal coronary circulation and the brain to receive the blood with the highest level of oxygenation. Deoxygenated blood from the superior vena cava flows into the right atrium, the right ventricle, and then the pulmonary artery. Because of high pulmonary vascular resistance, only a small percentage (5% to 10%) of the blood in the pulmonary artery flows to the lungs; the majority is shunted through the patent ductus arteriosus, and then to the descending aorta (American Heart Association [AHA], 2015). The fetal lungs are essentially nonfunctional because they are filled with fluid, making them resistant to incoming blood flow. They receive only enough blood for proper nourishment. Finally, two umbilical arteries carry the unoxygenated blood from the descending aorta back to the placenta. At birth, a dramatic change in the fetal circulatory pattern occurs. The foramen ovale, ductus arteriosus, ductus venosus, and umbilical vessels are no longer needed. With the newborn’s first breath, the lungs inflate, which leads to an increase in blood flow to the lungs from the right ventricle. This increase raises the pressure in the left atrium, causing a one-way flap on the left side of the foramen ovale, called the septum primum, to press against the opening, creating a functional separation between the two atria. Blood flow to the lungs increases because blood entering the right atrium can no longer bypass the right ventricle. As a result, the right ventricle pumps blood into the pulmonary artery and on to the lungs. Typically the foramen ovale is functionally closed within 1 to 2 hours after birth. It is physiologically closed by 1 month by deposits of fibrin that seal the shunt. Permanent closure occurs by the sixth month of life. The ductus venosus, which links the inferior vena cava with the umbilical vein, usually closes with the clamping of the umbilical cord and inhibition of blood flow through the umbilical vein. This fetal structure closes by the end of

the first week. The ductus arteriosus constricts partly in response to the higher arterial oxygen levels that occur after the first few breaths. This closure prevents blood from the aorta from entering the pulmonary artery. Functional closure of the ductus arteriosus in a term infant usually occurs within the first 72 hours after birth. Permanent closure occurs at 3 to 4 weeks of age (Yudkowitz, 2015). Frequently a functional or innocent murmur is auscultated by the nursery nurse when there are delayed fetal shunt closures, but they usually are not associated with a heart lesion. Successful transition from fetal to postnatal circulation requires increased pulmonary blood flow, removal of the placement and closure of the intracardiac (foramen ovale) and the extracardiac shunts (ductus venous and ductus arteriosus. All of these changes at birth leave the newborn with the typical adult pattern of circulation with right ventricle output equaling that of the left. Figure 10.9 shows fetal circulation. Also, view the following video of fetal circulation at this YouTube URL: https://www.youtube.com/watch? v=IRkisEtzskhttp://ndl.iitkgp.ac.in:8080/xmlui/handle/123456789/56006

GENETICS Genetics is the study of individual genes and their role in heritance (Snustad, 2015). Genomics, a relatively new science, is the study of all genes and includes interactions among genes as well as interactions between genes and the environment. Genomics plays a role in complex conditions such as heart disease and diabetes. Another emerging area of research is that of pharmacogenomics, the study of genetic and genomic influences on pharmacodynamics and pharmacotherapeutics. While pharmacogenetics describes genetic variations between individuals and their influence on the efficacy and side effects of drugs, pharmacogenomics examines interactions of drugs with the entire genome. The main goal of both fields is the individual prediction of desirable and undesirable drug effects. An individual’s genetics influences wellness and health issues throughout that individual’s life cycle. The challenge for health care providers is to find the link between the client’s genetic makeup and diseases (Brazeau, 2015). According to the Centers for Disease Control and Prevention (2015a), birth defects and genetic disorders occur in 1 in 33 infants born in the United States and cause 1 in 5 infant deaths. Every 5 minutes an infant is born with a birth defect in the United States with nearly 120,000 infants affected annually. Traditionally, genetics has been associated with making decisions about childbearing and caring for children with genetic disorders. Currently, genetic and technological advances are expanding our understanding of how genetic changes affect human diseases such as diabetes, cancer, Alzheimer’s disease, and other multifactorial diseases that are prevalent in adults. Today’s genetic technologies are not yet a crystal ball for seeing a child’s future, but scientists are closer to routinely glimpsing the genetic blueprints of a fetus just months after sperm meets egg. The genomic reconstruction would reveal future disease risk and genetic traits in the first trimester of pregnancy. Recent research findings report that preimplantation with knowledge of the whole genome may facilitate the comprehensive diagnosis of diseases with a known genetic basis in embryos (Kumar et al., 2015). Newborn screening is perhaps the most widely used application of genetics in perinatal and neonatal care. Our ability to diagnose genetic conditions is more advanced than our ability to cure or treat the disorders. However, accurate diagnosis has led to improved treatment and

outcomes for those affected with these disorders.

FIGURE 10.9 Fetal circulation. Arrows indicate the path of blood. The umbilical vein carries oxygen-rich blood from the placenta to the liver and through the ductus venosus. From there it is carried to the inferior vena cava to the right atrium of the heart. Some of the blood is shunted through the foramen ovale to the left side of the heart, where it is routed to the brain and upper extremities. The rest of the blood travels down to

the right ventricle and through the pulmonary artery. A small portion of the blood travels to the nonfunctioning lungs, while the remaining blood is shunted through the ductus arteriosus into the aorta to supply the rest of the body.

Take Note! Genetic science has the potential to revolutionize health care with regard to national screening programs, predisposition testing, detection of genetic disorders, and pharmacogenetics. Genetics has been a part of perinatal care for decades. Rapid development and implementation of advanced genetics technology in prenatal settings includes the ability to screen for and diagnose a broader range of diseases and conditions of the fetus in early gestational ages. Ultrasounds and maternal serum screening have become routine elements of prenatal care. Preconception carrier screening for conditions such as Tay–Sachs disease has been in place among high-risk populations such as Ashkenazi Jews. Amniocentesis and chorionic villus sampling are diagnostic tests that may confirm a genetic anomaly in a developing fetus, but they are all invasive techniques A fetal nuchal translucency test, seen on ultrasound, may suggest the presence of trisomy 21 or Down syndrome if increased nuchal thickness is found (Khalil & Coates, 2015). Testing for genetic diseases before they cause symptoms, making a diagnosis in a person who has disease symptoms, and prescribing a type or dose of medication is early in its evolution. Genetic testing currently is rarely covered by health insurance companies, as the tests are still thought of as in research stages. This will change over the next several years as more associations between genomics and health are discovered. Today, nurses are required to have basic skills and knowledge in genetics, genetic testing, and genetic counseling so they can assume new roles and provide information and support to women and their families. Roles for maternity nurses in genetic health care have expanded significantly as genetics education and counseling have become a standard of care. Today, nurses may provide preconception counseling for women at risk for the transmission of a genetic disorder. In addition, they may provide prenatal care for women with genetically linked disorders that require specialized care or may participate in screening infants for birth defects and genetic disorders. Nurses employed in

prenatal care settings need to have accurate information they can provide to women so they understand the benefits and limitations of screening. Timely presentation of information and identification of available resources will help nurses minimize a couple’s confusion and provide support for women as they proceed with pregnancy screening. Nurses at all levels should participate in risk assessments for genetic conditions and disorders, explaining genetic risk and genetic testing, and supporting informed health decisions and opportunities for early intervention (Farrell, Nutter, & Agatisa, 2015). Nurses have a social and professional responsibility to ensure they provide current accurate information to clients and their families amid rapidly developing technology. This is especially true for nurses who value and support well-informed decision making that is woman-and-family-centered. For further information suitable for client education, nurses may want to access the following CDC web page on genomics: http://www.cdc.gov/genomics/public/index.htm/ It is very clear that genomics will have a profound effect on health and illness at all levels. Modern technology makes it possible to screen for and diagnose conditions prior to birth, such as open neural tube defects, chromosomal aneuploidies (i.e., trisomies 13, 18, and 21), congenital defects, and a myriad of single gene inheritable disorders (i.e., Tay–Sachs disease, cystic fibrosis, Huntington’s disease, Duchenne muscular dystrophy, hemophilia). In the future, as the era of personalized health care moves forward, nurses will be responsible for ensuring that the scientific principles, ethical standards, and professional accountability of genetics and genomics practice are integrated into nursing practice. Nurses are increasingly doing this as they gain the necessary knowledge and skills. The strength of the nursing voice in genetics and genomic research will be the link to the bedside and the commitment to ensure that new knowledge is translated into competent, safe, effective, and evidence-based client care (Latendresse & Deneris, 2015).

Advances in Genetics and Genetic Technology Human Genome Project The publication of the first sequence of the human genome was regarded as one of the most ambitious and successful international research collaborations in modern biology. The Human Genome Project (HGP) was an international 13year effort to produce a comprehensive sequence of the human genome. It was started in 1990 by the Department of Energy and the National Institutes of Health and was completed in May 2003. The goals of the HGP were to map, sequence, and determine the function of all human genes, which led to advances in the field of genetics and genetic testing (Kumar, Kingsley, & DiStefano, 2015). An individual’s genome represents his or her genetic blueprint, which determines genotype (the gene pairs inherited from parents; the specific genetic makeup) and phenotype (observed outward characteristics of an individual). An individual’s genetic profile can help guide decisions made regarding prevention, diagnosing, and treating disease. This is a profound shift in thinking from genetics that addressed rare disorders to the use of genetic information in all aspects of health care (Wilson & Nicholls, 2015). A primary goal of the HGP was to translate the findings into new strategies for the prevention, diagnosis, and treatment of genetic diseases and disorders. Two key findings from the project were that all human beings are 99.9% identical at the deoxyribonucleic acid (DNA) level, and approximately 30,000 genes make up the human genome (International Human Genome Sequencing Consortium, 2015). Refer to for more information about the HGP.

Genetic Testing, Diagnosis, and Therapy Recent advances in genetic knowledge and technology have affected all areas of health. These advances have increased the number of health interventions that can be undertaken with regard to genetic disorders. For example, genetic diagnosis is now possible very early in pregnancy (Evidence-Based Practice 10.1). Genetic testing can now identify presymptomatic conditions in children and adults. Gene therapy can be used to replace or repair defective or missing genes with normal ones. Gene therapy has been used for a variety of disorders, including cystic fibrosis, melanoma, diabetes, HIV, and hepatitis. Gene therapy

offers the possibility of accurately and specifically targeting particular genetic abnormalities through gene correction, addition, or replacement. This ability adds a new dimension of credible therapeutic choices (Cicalese & Aiuti, 2015). The potential exists for creation of increased intelligence and size through genetic intervention. Recent research using gene therapy shows promise for the generation of insulin-producing cells to cure diabetes; perhaps achieve long-term control of diabetes is on the horizon. Recent research is working toward beta cell replacement for diabetics to reliably and automatically maintain glucose levels within a tight range as the normal pancreas does (Johannesson et al., 2015). In the future, genetic agents may replace drugs, general surgery may be replaced by gene surgery, and genetic intervention may replace radiation. Recent successful trials on the treatment of ocular diseases and inherited immune deficiencies are particularly encouraging and have risen hopes that human gene therapy as a standard treatment option will finally become a reality. Continuous progress suggests that a wide range of diseases will be treated with gene therapy in the future (Lundstrom, 2015).

EVIDENCE-BASED PRACTICE 10.1 EFFECT OF ENHANCED INFORMATION, VALUES CLARIFICATION, AND REMOVAL OF FINANCIAL BARRIERS ON USE OF PRENATAL GENETIC TESTING: A RANDOMIZED CLINICAL TRIAL Prenatal genetic testing guidelines have focused on identifying women at increased risk of giving birth to infants with chromosomal abnormalities. The use of prenatal genetic testing for clinical decision making is increasing exponentially. The current complexity of it brings concerns about the potential erosion of informed choice. It is difficult to ascertain if clients and their families truly understand what it is about and implications of the results. There currently are genetic tests for more than 2,500 diseases, with nearly 2,300 available for use in clinical decision making. The aim of this randomized study was to promote preference-based decision making and to assess the prenatal testing choices women make in the context of being fully informed about testing options.

STUDY Of 1,932 women screened, 1,297 were eligible, and 744 enrolled in the study. They were then randomized into interventional and control groups. The women were diverse in ethnicity, language, education, and were at 20 weeks’ gestation or less. Those in the intervention group had access to a computerized, interactive, prenatal testing support guide and were told that the study would pay for any tests for which they lacked health insurance coverage. Women in the control group received usual care, but no additional study intervention or financial support to cover prenatal testing. The goal was to determine what choices women would make after being fully informed about the benefits and risks of prenatal testing.

Findings After women received complete prenatal testing information and the opportunity to consider their values and preferences, they were less likely to undergo invasive testing and more likely to avoid testing for aneuploidy (i.e., trisomies 13, 18, and 21). Full implementation of prenatal testing guidelines may lead to more informed and preference-based prenatal decision making.

Nursing Implications Based on this study’s findings, nurses can utilize standard counseling in addition to computer-based interactive information to reinforce the information about genetic testing before decisions are made to proceed. The landscape for genetic testing is changing constantly and it is wise to have well-informed clients and their families making the right decisions for their situation. By utilizing computerized technology to assist in educating clients and their families about a vital decision affecting their future, nurses are providing evidence-based information to them. Nurses have a responsibility to be knowledgeable about available genetic tests so they can assist their clients to become informed consumers of genetic-based health care. Adapted from Kuppermann, M., Pena, S., Bishop, J. T., Nakagawa, S., Gregorich, S. E., Sit, A., et al. (2015). Effect of enhanced information, values clarification, and removal of financial barriers on use of prenatal genetic testing: A randomized clinical trial. Obstetrical & Gynecological Survey, 70(1), 7–9.

Current and potential applications of the HGP in health care include rapid and more specific diagnosis of disease, with hundreds of genetic tests available in research or clinical practice; earlier detection of genetic predisposition to disease; less emphasis on treating the symptoms of a disease and more emphasis on looking at the fundamental causes of the disease; new classes of drugs; avoidance of environmental conditions that may trigger disease; and augmentation or replacement of defective genes through gene therapy. This new genetic knowledge and technology, along with the commercialization of this knowledge, will change both professional and parental understanding of genetic disorders. Current reproductive applications, however, remain restricted to mostly the prevention of transmitting an at-risk gene or genes, but do not include treatment or cure. It is anticipated that this restriction might continue for years. As such, the scientific and ethical issues associated with reproductive applications will continue to affect decision making of at-risk individuals.

Ethical, Legal, and Social Issues of Genetic Technology The potential benefits of these discoveries are vast, but so is the potential for

misuse. These advances challenge all health care providers to consider the many ethical, legal, and social ramifications of genetics in human lives. In the near future, individual risk profiling based on an individual’s unique genetic makeup will be used to tailor prevention, treatment, and ongoing management of health conditions. This profiling will raise issues associated with client privacy and confidentiality related to workplace discrimination and access to health insurance. Issues of autonomy are equally problematic as society considers how to address the injustices that will inevitably surface when disease risk can be determined years before the disease occurs. Nurses will play an important role in developing policies and providing direction and support in this arena, and to do so they will need a basic understanding of genetics, including inheritance and inheritance patterns. (For more information on the ethical, social, and legal issues surrounding human genetic research and advances, refer to ).

Inheritance DNA and Genetic Information The nucleus within the cell is the controlling factor in all cellular activities because it contains chromosomes, long continuous strands of DNA that carry genetic information. Each chromosome is made up of genes. Genes are individual units of heredity of all traits and are organized into long segments of DNA that occupy a specific location on a chromosome and determine a particular characteristic in an organism. DNA stores genetic information and encodes the instructions for synthesizing specific proteins needed to maintain life. DNA is double stranded and takes the form of a double helix. The side pieces of the double helix are made up of a sugar, deoxyribose, and a phosphate, occurring in alternating groups. The crossconnections or rungs of the ladder are attached to the sides and are made up of four nitrogenous bases: adenine, cytosine, thymine, and guanine. The sequence of the base pairs as they form each rung of the ladder is referred to as the genetic code (Travers & Muskhelishvili, 2015) (Fig. 10.10). Each gene has a segment of DNA with a specific set of instructions for making proteins needed by body cells for proper functioning. Genes control the types of proteins made and the rate at which they are produced (Snustad, 2015). Any change in gene structure or location leads to a mutation, which may alter the type and amount of protein produced (Fig. 10.11). Genes never act in isolation; they always interact with other genes and the environment. They are arranged and lined up in a specific linear formation along a chromosome.

FIGURE 10.10 DNA is made up of four chemical bases. Tightly coiled strands of DNA are packaged in units called chromosomes, housed in the cell’s nucleus. Working subunits of DNA are known as genes. (From the National Institutes of Health and National Cancer Institute. [1995]. Understanding gene testing [NIH Pub. No. 96-3905]. Washington, DC: U.S. Department of Human Services).

FIGURE 10.11 When a gene contains a mutation, the protein encoded by that gene will be abnormal. Some protein changes are insignificant, while others are disabling. (From the National Institutes of Health and National Cancer Institute. [1995]. Understanding gene testing [NIH Pub. No. 96-3905]. Washington, DC: U.S. Department of Human Services).

Genotypes and Alleles The genotype—the specific genetic makeup of an individual, usually in the form of DNA—is the internally coded inheritable information. It refers to the particular allele, which is one of two or more alternative versions of a gene at a given position or locus on a chromosome that imparts the same characteristic of that gene. For instance, each human has a gene that controls height, but there are variations of these genes, called alleles, that code for a specific height. As another example, a gene that controls eye color may have an allele that can produce blue eyes or an allele that produces brown eyes. The genotype, together with environmental variation that influences the individual, determines the phenotype, or the observed, outward characteristics of an individual. A human inherits two genes, one from each parent. Therefore, one allele comes from the mother and one from the father. These alleles may be the same for the characteristic (homozygous) or different (heterozygous). For example, WW stands for homozygous dominant; ww stands for homozygous recessive. Heterozygous would be indicated as Ww. If the two alleles differ, such as Ww, the dominant one will usually be expressed in the phenotype of the individual.

Chromosomes Human beings typically have 46 chromosomes. This includes 22 pairs of nonsex chromosomes or autosomes and 1 pair of sex chromosomes (two X chromosomes in females, and an X chromosome and a Y chromosome in males). Offspring receive one chromosome of each of the 23 pairs from each parent. The pictorial analysis of the number, form, and size of an individual’s chromosomes is termed the karyotype. This analysis commonly uses white blood cells and fetal cells in amniotic fluid. The chromosomes are numbered from the largest to the smallest, 1 to 22, and the sex chromosomes are designated by the letter X or Y. A female karyotype is designated as 46, XX and a male karyotype is designated as 46, XY. Figure 10.12 illustrates an example of a karyotyping pattern.

Genetic Mutations Regulation and expression of the thousands of human genes are very complex processes and are the result of many intricate interactions within each cell. Alterations in gene structure, function, transcription, translation, and protein synthesis can influence an individual’s health (Jones & Lopez, 2014). Gene mutations are a permanent change in the sequence of DNA. Gene mutations can be inherited, spontaneous, or acquired. Inherited gene mutations are passed on from parent to child in the egg and sperm, and are passed on to all cells in that child’s body when the body cells reproduce. Cystic fibrosis is an example of an inherited mutation. A spontaneous mutation can occur in individual eggs or sperm at the time of conception. A person who has the new spontaneous mutation has the risk of passing it on to his or her offspring. An example of a spontaneous mutation would be Marfan syndrome. Acquired mutations occur in body cells other than egg or sperm. They involve changes in DNA that take place after conception, during a person’s lifetime. Acquired mutations are passed on when they reproduce to daughter cells. These changes can be caused by environmental factors such as ultraviolet radiation from the sun, or can occur if a mistake is made as DNA copies itself during cell division (National Institutes of Health [NIH], 2015a). Some mutations have no significant effect, whereas others can have a tremendous impact on the health of the individual. Several genetic disorders such as cancer, sickle cell disease, PKU, and hemophilia, can result from these mutations.

FIGURE 10.12 Karyotype pattern. A. Normal female karyotype. B. Normal male karyotype.

Patterns of Inheritance for Genetic Disorders Patterns of inheritance demonstrate how a genetic disorder can be passed on to offspring. A genetic disorder is a disease caused by an abnormality in an individual’s genetic material or genome. Diagnosis of a genetic disorder is usually based on clinical signs and symptoms or on laboratory confirmation of the presence of an altered gene associated with the disorder. Accurate diagnosis can be aided by recognition of the pattern of inheritance within a family. The pattern of inheritance is also vital to understand when teaching and counseling families about the risks in future pregnancies. Some genetic conditions are caused by mutations in a single gene. These conditions are typically inherited in one of several straightforward patterns, depending on the gene involved. Some genetic disorders occur in multiple family members, while others may occur in only a single family member. A genetic disorder is caused by completely or partially altered genetic material, whereas a familial disorder is more common in relatives of the affected individual but may be caused by environmental influences and not genetic alterations.

Monogenic Disorders The principles of genetic disease inheritance of single-gene disorders are the same principles that govern the inheritance of other traits, such as eye and hair color. These are known as Mendel’s laws of inheritance, named for the genetic work of Gregor Mendel, an Austrian naturalist. These patterns occur due to a single gene being defective and are referred to as monogenic or sometimes Mendelian disorders. If the defect occurs on the autosome, the genetic disorder is termed autosomal; if the defect is on the X chromosome, the genetic disorder is termed X linked. The defect also can be classified as dominant or recessive. Monogenic disorders include autosomal dominant, autosomal recessive, Xlinked dominant, and X-linked recessive patterns. AUTOSOMAL DOMINANT INHERITANCE DISORDERS Autosomal dominant inheritance disorders occur when a single gene in the heterozygous state is capable of producing the phenotype. In other words, the abnormal or mutant gene overshadows the normal gene and the individual will demonstrate signs and symptoms of the disorder. The affected person generally

has one affected parent, and an affected person has a 50% chance of passing the abnormal gene to each of his or her children (Fig. 10.13). Affected individuals are present in every generation. Males and family members who are phenotypically normal (do not show signs or symptoms of the disorder) do not transmit the condition to their offspring. Females and males are equally affected and a male can pass the disorder on to his son. This male-to-male transmission is important in distinguishing autosomal dominant inheritance from X-linked inheritance. There are varying degrees of presentation among individuals in a family. Therefore, a parent with a mild form could have a child with a more severe form. Common types of genetic disorders that follow the autosomal dominant pattern of inheritance include neurofibromatosis (genetic disorders affecting the development and growth of neural cells and tissues); Huntington’s disease (a genetic disorder affecting the nervous system characterized by abnormal involuntary movements and progressive dementia); achondroplasia (a genetic disorder resulting in disordered growth and abnormal body proportion); and polycystic kidney disease (a genetic disorder involving the growth of multiple, bilateral, grape-like clusters of fluid-filled cysts in the kidneys that eventually compress and replace functioning renal tissue).

FIGURE 10.13 Autosomal dominant inheritance.

AUTOSOMAL RECESSIVE INHERITANCE DISORDERS Autosomal recessive inheritance disorders occur when two copies of the mutant or abnormal gene in the homozygous state are necessary to produce the phenotype. In other words, two abnormal genes are needed for the individual to demonstrate signs and symptoms of the disorder. These disorders are generally less common than autosomal dominant disorders (NIH, 2015a). Both parents of the affected person must be heterozygous carriers of the gene (clinically normal but carry the gene), and their offspring have a 25% chance of being homozygous (a 50% chance of getting the mutant gene from each parent and therefore a 25% chance of inheriting two mutant genes). If the child is clinically normal, there is a 50% chance that he or she is a carrier (Fig. 10.14). Affected individuals are usually present in only one generation of the family. Females and males are equally affected and a male can pass the disorder on to his son. The chance that any two parents will both be carriers of the mutant gene is increased if the couple is consanguineous (having a common ancestor). Common types of genetic disorders that follow the autosomal recessive inheritance pattern include cystic fibrosis (a genetic disorder involving generalized dysfunction of the exocrine glands); PKU (a disorder involving a deficiency in a liver enzyme that leads to the inability to process the essential amino acid phenylalanine); Tay– Sachs disease (a disorder due to insufficient activity of the enzyme hexosaminidase A, which is necessary for the breakdown of certain fatty substances in the brain and nerve cells); and sickle cell disease (a genetic disorder in which the red blood cells carry an ineffective type of hemoglobin instead of the normal adult hemoglobin).

FIGURE 10.14 Autosomal recessive inheritance.

X-LINKED INHERITANCE DISORDERS X-linked inheritance disorders are those associated with altered genes present on the X chromosome. They differ from autosomal disorders. If a male inherits an X-linked altered gene, he will express the condition. Because a male has only one X chromosome, all the genes on his X chromosome will be expressed (the Y chromosome carries no normal allele to compensate for the altered gene). Because females inherit two X chromosomes, they can be either heterozygous or homozygous for any allele. Therefore, X-linked disorders in females are expressed similarly to autosomal disorders. Concept Mastery Alert Male Children in Pattern of Inheritance of Duchenne Muscular Dystrophy The gene for Duchenne muscular dystrophy is X-linked, which means that a male child who inherits this gene will be affected by, not a carrier of, the

disease. A female child will not be affected by the disease.

Most X-linked disorders demonstrate a recessive pattern of inheritance. Males are more affected than females. A male has only one X chromosome and all the genes on his X chromosome will be expressed, whereas a female will usually need both X chromosomes to carry the disease. There is no male-to-male transmission (since no X chromosome from the male is transmitted to male offspring), but any man who is affected will have carrier daughters. If a woman is a carrier, there is a 50% chance that her sons will be affected and a 50% chance that her daughters will be carriers (Fig. 10.15). Common types of genetic disorders that follow X-linked recessive inheritance patterns include hemophilia (a genetic disorder involving a deficiency of one of the coagulation factors in the blood); color blindness; and Duchenne muscular dystrophy (a disorder involving progressive muscular weakness and wasting). X-linked dominant inheritance is present if heterozygous female carriers demonstrate signs and symptoms of the disorder. All of the daughters and none of the sons of an affected male have the condition, while both male and female offspring of an affected woman have a 50% chance of inheriting and presenting with the condition (Fig. 10.16). X-linked dominant disorders are rare. The most common is hypophosphatemic (vitamin D–resistant) rickets (a disorder involving a softening or weakening of the bones). Fragile X syndrome is another X-linked dominant condition that causes a range of developmental problems including learning disabilities and cognitive impairment. A characteristic of Xlinked dominant is that fathers cannot pass X-linked traits to their sons (no maleto-male transmission).

FIGURE 10.15 X-linked recessive inheritance.

FIGURE 10.16 X-linked dominant inheritance.

Multifactorial Inheritance Disorders Multifactorial inheritance disorders are thought to be caused by multiple genetic (polygenic) and environmental factors. Many of the common congenital malformations, such as cleft lip, cleft palate, spina bifida, pyloric stenosis, clubfoot, developmental hip dysplasia, and cardiac defects, are attributed to multifactorial inheritance. A combination of genes from both parents, along with unknown environmental factors, produces the trait or condition. An individual may inherit a predisposition to a particular anomaly or disease. The anomalies or diseases vary in severity, and often a sex bias is present. For example, pyloric stenosis is seen more often in males, while developmental hip dysplasia is much more likely to occur in females. Multifactorial conditions tend to run in families, but the pattern of inheritance is not as predictable as with single-gene disorders. The chance of recurrence is also lower than in single-gene disorders, but the degree of risk is related to the number of genes in common with the affected individual. The closer the degree of relationship, the more genes an individual has in common with the affected family member, resulting in a higher chance that the individual’s offspring will have a similar defect. In multifactorial inheritance, the likelihood that both identical twins will be affected is not 100%, indicating that there are nongenetic factors involved.

Nontraditional Inheritance Patterns Molecular studies have revealed that some genetic disorders are inherited in ways that do not follow the typical patterns of dominant, recessive, X-linked, or multifactorial inheritance. Examples of nontraditional inheritance patterns include mitochondrial inheritance and genomic imprinting. As the science of molecular genetics advances and more is learned about inheritance patterns, other nontraditional patterns of inheritance may be discovered or found to be relatively common.

Chromosomal Abnormalities In some cases of genetic disorders, the abnormality occurs due to problems with the chromosomes. Chromosomal abnormalities arise when the normal complement of 46 chromosomes that produces a karyotype is altered, usually during cell division, either by an increase or decrease in the number of chromosomes. About 1 in 150 live-born infants is born with a chromosomal abnormality (March of Dimes, 2015a). These often cause major defects because they involve added or missing genes. Congenital anomalies and intellectual disability are often associated with chromosomal abnormalities. These abnormalities occur on autosomal as well as sex chromosomes and can result from changes in the number of chromosomes or changes in the structure of the chromosomes.

Numerical Abnormalities Chromosomal abnormalities of number often result from nondisjunction or failure of the chromosome pair to separate during cell division, meiosis, or mitosis. Few chromosomal numerical abnormalities are compatible with fullterm development and most result in spontaneous abortion. One type of chromosomal number abnormality is polyploidy. Polyploidy causes an increase in the number of haploid sets (23) of chromosomes in a cell. Triploidy refers to three whole sets of chromosomes in a single cell (in humans, a total of 69 chromosomes per cell); tetraploidy refers to four whole sets of chromosomes in a single cell (in humans, a total of 92 chromosomes per cell). Polyploidy usually results in an early spontaneous abortion and is incompatible with life. Some numerical abnormalities do support development to term because the chromosome on which the abnormality is present carries relatively few genes (such as chromosome 13, 18, 21, or X). Two common abnormalities of chromosome number are monosomies or trisomies. In monosomies, there is only one copy of a particular chromosome instead of the usual pair (an entire single chromosome is missing). In these cases, all fetuses spontaneously abort in early pregnancy. Survival is seen only in mosaic forms of these disorders. In trisomies, there are three of a particular chromosome instead of the usual two (an entire single chromosome is added). Trisomies may be present in every cell or may present in the mosaic form. The most common trisomies include trisomy

21 (Down syndrome), trisomy 18, and trisomy 13. TRISOMY 21 Down syndrome is an example of a trisomy. The cause of Down syndrome is one of three types of abnormal cell division involving chromosome 21. All three abnormalities result in extra genetic material from chromosome 21, which is responsible for the characteristic features and developmental problems of Down syndrome. The three genetic variations that can cause Down syndrome include trisomy 21, where the infant has three copies of chromosome 21—instead of the usual two copies—in all of his or her cells; mosaic, where infants have some cells with an extra copy of chromosome 21; and translocation, where part of chromosome 21 becomes attached (translocated) to another chromosome, before or at conception. More than 90% of the cases of Down syndrome are caused by trisomy 21 (March of Dimes, 2015b) (Fig. 10.17). Down syndrome affects 1 in 691 live-born babies. About 6,000 infants with Down syndrome are born in the United States annually. The risk of this and other trisomies increases with maternal age. The risk of having a baby with Down syndrome is about 1 in 1,250 for a woman at age 25, 1 in 1,000 at 30, 1 in 400 at 35, 1 in 100 at age 40, and 1 in 30 at age 45 (March of Dimes, 2015b). Children with Down syndrome have characteristic features that are usually identified at birth (Fig. 10.18). These common characteristics include:

FIGURE 10.17 Karyotype of a child with Down syndrome.

• Small, low-set ears that may fold over a little at the pinna • Hyperflexibility • Muscle hypotonia

• Small hands and feet • A short neck • Wide-spaced eyes that slant upward • Ulnar loop on the second digit • Deep crease across palm (termed a simian crease) • Flat facial profile • Short stature in childhood and adulthood • Small white, crescent-shaped spots on irises • Small mouth with protruding tongue • Broad, short fingers (National Down Syndrome Society [NDSS], 2015a) The outlook for children with Down syndrome is much brighter now than it was years ago. Most children with Down syndrome have an intellectual disability in the mild-to-moderate range. With early intervention and special education, many learn to read and write and participate in diverse childhood activities (Grieco et al., 2015). Life expectancy for individuals with Down syndrome has increased dramatically in recent years, with the average life span approaching that of peers without Down syndrome (NDSS, 2015b). TRISOMY 18 AND TRISOMY 13 Two other common trisomies are trisomy 18 and trisomy 13. Trisomy 18 and trisomy 13 are, respectively, the second and third most commonly diagnosed autosomal trisomies in live-born infants. These conditions are associated with a high degree of infant mortality, with most dying before their first birthday (Trisomy 18 Foundation, 2015). Trisomy 18, or Edward syndrome, occurs in 1 of every 2,500 pregnancies in the United States, about 1 in 6,000 live births (Trisomy 18 Foundation, 2015). Prenatally, several findings are apparent on ultrasound: IUGR, hydramnios or oligohydramnios, cardiac malformations, a single umbilical artery, and decreased fetal movement. Additionally, trisomy 18 has been associated with a decrease in maternal serum levels of maternal serum alpha-fetoprotein (MSAFP) and hCG. Most affected newborns are female, with a 4:1 ratio to males. Affected newborns have 47 chromosomes (three at chromosome 18) and are characterized by severe intellectual disability, growth deficiency of the cranium (microcephaly), low-set ears, facial malformations, small-for-gestational-age size, seizures, drooping

eyelids, webbing of fingers, kidney and congenital heart defects, rocker-bottom feet, and severe hypotonia (National Organization for Rare Disorders [NORD], 2015a). Infants with trisomy 18 have multiple anomalies that are severe, and life expectancy is greatly reduced beyond a few months.

FIGURE 10.18 A. Typical facial features of an infant with Down syndrome. B. A simian line, a horizontal crease in the palm of children with Down syndrome.

FIGURE 10.19 An infant with trisomy 13 has supernumerary digits (polydactyly).

Trisomy 13, or Patau syndrome, affects 1 of 10,000 live births (Support Organization for Trisomies [SOFT], 2015). Forty-seven chromosomes (three of chromosome 13) are present. Maternal age is also thought to be a causative factor in this genetic disorder. The common abnormalities associated with trisomy 13 are microcephaly, cardiac defects, small eyes, kidney malformations, central nervous system anomalies, rocker-bottom feet, neural tube defects, omphalocele, cleft lip and palate, cryptorchidism, polydactyly (Fig. 10.19), severe intellectual disability, severe hypotonia, and seizures. Life expectancy is only a few days for most infants with trisomy 13 (NORD, 2015b). Care for these infants is supportive.

Structural Abnormalities Chromosomal abnormalities of structure usually occur when a portion of one or more chromosomes is broken or lost, and during the repair process the broken ends are rejoined incorrectly. Structural abnormalities usually lead to having too much or too little genetic material. Altered chromosome structure can take on several forms. Deletions occur when a portion of the chromosome is missing, resulting in a loss of that chromosomal material. Duplications are seen when a portion of the chromosome is duplicated and an extra chromosomal segment is present. Clinical findings vary depending on how much chromosomal material is involved. Inversions occur when a portion of the chromosome breaks off at two points and is turned upside down and reattached; therefore, the genetic material is inverted. The most clinically significant structural abnormality is a translocation. This occurs when part of one chromosome is transferred to another chromosome and an abnormal rearrangement is present. Structural abnormalities can be balanced or unbalanced. Balanced abnormalities involve the rearrangement of genetic material with neither an

overall gain nor loss. Individuals who inherit a balanced structural abnormality are usually phenotypically normal but are at a higher risk for miscarriages and having chromosomally abnormal offspring. Examples of structural rearrangements that can be balanced include inversions, translocations, and ring chromosomes. Unbalanced structural abnormalities are similar to numerical abnormalities because genetic material is either gained or lost. Unbalanced structural abnormalities can encompass several genes and result in severe clinical consequences. CRI DU CHAT SYNDROME Cri du chat (“cry of the cat”) syndrome is a rare genetic disorder in which a variable portion of the short arm of chromosome 5 is missing or deleted. It was named “cri du chat” based on the distinctive cry in newborns that resembles the mewing of a cat, which is due to a laryngeal defect. The incidence of the disorder is thought to be approximately 1 in 50,000 live births (NORD, 2015d). In addition to the cat-like, high-pitched cry in infancy, it is also associated with intellectual and psychomotor disability, microcephaly, speech delay, low birth weight and slow growth, hypotonia, failure to thrive, wide-set eyes, small jaw, low-set ears, and various organ malformations. Symptoms vary greatly from case to case depending upon the exact size and location of the deleted genetic material. No specific treatment is available for this syndrome. With contemporary interventions, the child may survive to adulthood: 75% of deaths occur during the first several months of life and almost 90% occur in the first year. Death occurs in 6% to 8% of the overall population affected with the syndrome. Pneumonia, aspiration pneumonia, congenital heart defects, and respiratory distress are the common causes of death (Chen, 2015a). Parents should be referred for genetic counseling. FRAGILE X SYNDROME Fragile X syndrome, also termed Martin–Bell syndrome, is a structural abnormality involving the X chromosome, which demonstrates breaks and gaps. It is a common form of intellectual disability and autism spectrum disorder. The syndrome is usually diagnosed by the age of 3 by molecular DNA studies. Conservative estimates report that fragile X syndrome affects approximately 1 in 5,000 males and 1 in 8,000 females (CDC, 2015c). Typically, a female becomes the carrier and will be mildly affected. The male who receives the X

chromosome that has a fragile site will exhibit the full effects of the syndrome. Fragile X syndrome is characterized by intellectual disability, hyperactivity, large head, long face, short attention span, hand flapping, strabismus, hypotonia, speech delay, inflexible behavior, autistic-like behavior, poor eye contact, tactile defensiveness, double-jointedness, and perseverative speech (continued repetition of words or phrases). It is the most common form of male intellectual disability (NORD, 2015e). Aside from the morbidity associated with intellectual disability and cognitive/behavioral/neuropsychological problems, the life span of an individual with fragile X syndrome is unaffected. This syndrome is currently not included in newborn screening panels in the United States, as it does not meet the standards for recommendation. There is no cure for this disorder. Speech, occupational, and physical therapy services usually are needed, as well as special education and counseling.

Sex Chromosome Abnormalities Chromosomal abnormalities can also involve sex chromosomes. These cases are usually less severe in their clinical effects than autosomal chromosomal abnormalities. Sex chromosome abnormalities are gender specific and involve a missing or extra sex chromosome. They affect sexual development and may cause infertility, growth abnormalities, and possibly behavioral and learning problems. Many affected individuals lead essentially normal lives. Examples are Turner syndrome (in females) and Klinefelter syndrome (in males). TURNER SYNDROME Turner syndrome is a common abnormality of the sex chromosome in which a portion or all of the X chromosome is missing. It affects about 1 in 2,000 liveborn female infants worldwide (March of Dimes, 2015a). It is highly variable and can differ dramatically from one person to another. Most cases of Turner syndrome are not inherited. Clinical manifestations include a low posterior hairline and webbing of the neck, short stature, broad skeletal abnormalities, kidney abnormalities, osteoporosis, heart defects, a shield-like chest with widely spaced nipples, lymphedema, cataracts, scoliosis, puffy feet, underdeveloped secondary sex characteristics, heart defects, and infertility (NORD, 2015c). Only about a third of cases are diagnosed as newborns; the remaining two thirds are diagnosed in early adolescence when they experience primary amenorrhea. No

cure exists for this syndrome. Growth hormone typically is given; hormone replacement therapy also may be used to induce puberty and stimulate continued growth. Most females with Turner syndrome are of normal intelligence and usually live essentially normal lives (NIH, 2015b). KLINEFELTER SYNDROME Klinefelter syndrome is a sex chromosomal abnormality that occurs only in males. About 1 in 500 to 1,000 males are born with Klinefelter syndrome (Chen, 2015b). With this syndrome an extra X chromosome (XXY) is present. The extra genetic material causes abnormal development of the testicles, resulting in decreased production of sperm and male sex hormones. Clinical manifestations may include: • Mild intellectual disability • Small testes that do not produce adequate testosterone • Infertility • Learning disabilities • Delayed speech and language development • Long arms and legs • Enlarged breast tissue (gynecomastia) • Scant facial and body hair • Decreased sex drive (libido) (NORD, 2015f) No treatment can correct this genetic abnormality, but testosterone replacement therapy can improve symptoms resulting from the deficiency. Surgery may be done to reduce gynecomastia. Most males with Klinefelter syndrome (XXY) are diagnosed in late puberty. Infertility is common and life expectancy is normal (Chen, 2015b).

Genetic Evaluation and Counseling Genetic counseling is the process by which clients or relatives at risk for an inherited disorder are advised of the consequences and nature of the disorder, the probability of developing or transmitting it, and the options open to them in management and family planning in order to prevent, avoid, or ameliorate it. Nurses have long been on the forefront of genetic counseling for their clients. The knowledge derived from the HGP is transforming the health care model, with implications for nursing in genetic counseling, practice, and research (Lopes, de Omena Bomfim, & Flória-Santos, 2015). An individual should be referred for genetic counseling for any of a variety of reasons. Box 10.2 lists those who may benefit from genetic counseling. In many cases, geneticists and genetic counselors provide information to families regarding genetic diseases. However, an experienced family physician, pediatrician, or nurse who has received special training in genetics may also provide the information.

Consider This

As I waited for the genetic counselor to come into the room, my mind was filled with numerous fears and questions. What does an inconclusive amniocentesis really mean? What if this pregnancy produced an abnormal baby? How would I cope with a special child in my life? If only I had gone to the midwife sooner when I thought I was pregnant, but still in denial. Why did I not stop drinking and smoking when I found out I was pregnant? If only I had started to take my folic acid pills when prescribed. Why didn’t I research my family’s history to know of any hidden genetic conditions? What about my sister with a Down syndrome child? What must I have been thinking? I guess I could play the “what-if” game forever and never come up with answers. Is it was too late to do anything about this? I am 37 years old and alone…. I started to pray silently when the counselor opened the door…. Thoughts: This woman is reviewing the past few weeks, looking for answers to her greatest fears. Inconclusive screenings can introduce emotional torment for many women as they wait for validating results. Are

these common thoughts and fears for many women facing potential genetic disorders? What supportive interventions might the nurse offer?

BOX 10.2 THOSE WHO MAY BENEFIT FROM GENETIC COUNSELING • Women who are pregnant or planning to be after age 35 • Paternal age 50 years or older • Previous child, parents, or close relatives with an inherited disease, congenital anomalies, metabolic disorders, developmental disorders, or chromosomal abnormalities • Consanguinity or incest • Pregnancy screening abnormality, including alpha-fetoprotein, triple screen, amniocentesis, or ultrasound • Stillborn with congenital anomalies • Two or more pregnancy losses • Exposure to drugs, medications, radiation, chemicals, or infections • Concerns about genetic defects that occur frequently in their ethnic or racial group (for instance, those of African descent are most at risk for having a child with sickle cell anemia) • Abnormal newborn screening • Couples with a family history of X-linked disorders • Carriers of autosomal recessive or dominant diseases • Child born with one or more major malformations in a major organ system • Child with abnormalities of growth • Child with developmental delay, intellectual disability, blindness, or deafness Adapted

from

March

of

Dimes.

(2015d).

Genetic

counseling.

Retrieved

from

http://www.marchofdimes.com/pregnancy/genetic-counseling.aspx; National Human Genome Research Institute.(2015).

What

is

genetic

counseling

and

evaluation?

Retrieved

from

https://www.genome.gov/19016905; and Dayal, M. B., & Athanasiadis, I. (2015). Preimplantation genetic diagnosis. eMedicine. Retrieved from http://emedicine.medscape.com/article/273415overview#aw2aab6b3.

A genetic consultation involves evaluation of an individual or a family. Its purposes are to confirm, diagnose, or rule out genetic conditions; to identify medical management issues; to calculate and communicate genetic risks to a family; to discuss ethical and legal issues; and to provide and arrange psychosocial support. Genetic counselors serve as educators and resource persons for other health care providers and the general public. The ideal time for genetic counseling is before conception. Preconception counseling gives couples the chance to identify and reduce potential pregnancy risks, plan for known risks, and establish early prenatal care. Unfortunately, many women delay seeking prenatal care until their second or third trimester, after the crucial time of organogenesis. Therefore, it is important that preconception counseling be offered to all women as they seek health care throughout their childbearing years, especially if they are contemplating pregnancy. This requires health care providers to take a proactive role. Genetic screening and counseling can raise serious ethical and moral issues for a couple. The results of prenatal genetic testing can lead to the decision to terminate a pregnancy, even if the results are not conclusive but indicate a strong possibility that the child will have an abnormality. The severity of the abnormality may not be known, and some may find the decision to terminate unethical. Another difficult situation that provides an example of the ethical and moral issues surrounding genetic screening and counseling involves disorders that affect only one gender of offspring. A mother may find she is a carrier of a gene for a disorder for which there is no prenatal screening test available. In these cases, the couple may decide to terminate any pregnancy where the fetus is the affected sex, even though there is a 50% chance that the child will not inherit the disorder. In these situations, the choice is the couple’s and information and support must be provided in a nondirective, nonjudgmental manner. Genetic counseling is particularly important if a congenital anomaly or genetic disease has been diagnosed prenatally or if a child is born with a life-threatening congenital anomaly or genetic disease. In these cases, families need information urgently so they can make immediate decisions. If a diagnosis with genetic implications is made later in life, if a couple with a family history of a genetic disorder or a previous child with a genetic disorder is planning a family, or if there is suspected teratogen exposure, urgency of information is not such an issue. In these situations, the family needs time to ponder all their options. This may involve several meetings over a longer period of time. Genetic counseling involves gathering information regarding birth history,

past medical history, and current health status as well as a family history of congenital anomalies, intellectual disability, genetic diseases, reproductive history, general health, and causes of death. A detailed family history is imperative and in most cases will include the development of a pedigree, which is like a family tree (Fig. 10.20). Information is ideally gathered on three generations, but if the family history is complicated, information from more distant relatives may be needed. Families receiving genetic counseling may benefit from being told in advance that this information will be necessary; they may need to discuss these sensitive, private issues with family members to obtain the needed facts. When necessary, medical records may be requested for family members, especially those who have a genetic disorder, to help ensure accuracy of the information. Sometimes a pedigree may reveal confidential information not known by all family members, such as an adoption, a child conceived through in vitro fertilization, or a husband not being the father of a baby. Therefore, maintaining confidentiality is extremely important. After careful analysis of the data obtained, referral to a genetic counselor when indicated is appropriate.

FIGURE 10.20 A pedigree is a diagram made using symbols that demonstrates the links between family members and focuses on medical and health information for each relative.

Medical genetic knowledge has increased dramatically during the past few decades. Not only is it possible to detect specific diseases with genetic mutations, but it is also possible to test for a genetic predisposition to various diseases or conditions and certain physical characteristics. This leads to complex ethical, moral, and social issues. Maintaining client privacy and confidentiality

and administering care in a nondiscriminatory manner are essential while maintaining sensitivity to cultural differences. It is essential to respect client autonomy and present information in a nondirective, nonjudgmental manner.

NURSING ROLES AND RESPONSIBILITIES Nurses are at the forefront of client care, and will participate fully in geneticbased and genomic-based activities. Nurses will therefore have a critical role advocating for, educating, counseling, and supporting clients and families who are making gene-based health care decisions (Association of Genetic Nurses and Counselors [AGNC], 2015). The nurse is likely to interact with the client in a variety of ways related to genetics: taking a family history, scheduling genetic testing, explaining the purposes of all screening and diagnostic tests, answering questions, providing information and psychosocial support to individuals and families, and addressing concerns raised by family members. Nurses are often the first health care providers to encounter women with preconception and prenatal issues. Nurses play an important role in beginning the preconception counseling process and referring women and their partners for further genetic testing when indicated. Nurses working with families involved with genetic counseling typically have certain responsibilities. These include: • Using interviewing and active listening skills to identify genetic concerns • Knowing basic genetic terminology and inheritance patterns • Explaining basic concepts of probability and disorder susceptibility • Safeguarding the privacy and confidentiality of clients’ genetic information • Providing complete informed consent to facilitate decisions about genetic testing • Discussing costs of genetic services and the benefits and risks of using health insurance to pay for genetic services, including potential risks of discrimination • Recognizing and defining ethical, legal, and social issues • Providing accurate information about the risks and benefits of genetic testing • Using culturally appropriate methods to convey genetic information • Monitoring clients’ emotional reactions after receiving genetic analysis • Providing information on appropriate local support groups • Knowing their own limitations and making appropriate referrals (Sermon &

Viville, 2014) An accurate and thorough family history is an essential part of preconception counseling. Nurses in any practice setting can obtain a client’s history during the initial encounter. The purpose is to gather client and family information that may provide clues as to whether the client has a genetic trait, inherited condition, or inherited predisposition (International Society of Nurses in Genetics, 2015). At a basic level, all nurses should be able to take a family medical history to help identify those at risk for genetic conditions, and then initiate a referral when appropriate. Box 10.3 presents examples of focused assessment questions that can be used. Based on the information gathered during the history, the nurse must decide whether a referral to a genetic specialist is necessary or whether further evaluation is needed. Families identified with genetic issues need unique clinical care including management of acute illnesses, screening for long-term complications, discussion of the etiology of the condition, connections to social supports, and clarification of the recurrence risks and prenatal testing and treatment options. Prenatal testing to assess for genetic risks and defects might be used to identify genetic disorders. These tests are described in Common Laboratory and Diagnostic Tests 10.1. Remember Robert and Kate Shafer? Based on the information gathered from their genetic history, they were referred to a genetic specialist. What prenatal tests might be ordered to assess their risk for genetic disorders? What would be the nurse’s role related to genetic counseling?

COMMON LABORATORY AND DIAGNOSTIC TESTS 10.1

BOX 10.3 FOCUSED HEALTH ASSESSMENT: GENETIC HISTORY • What was the cause and age of death for deceased family members? • Does any consanguinity exist between relatives? • Do any serious illnesses or chronic conditions exist? If so, what was the age of onset? • Do any female family members have a history of miscarriages, stillbirths, or diabetes? • Do any female members have a history of alcohol or drug use during pregnancy? • What were the ages of female members during childbearing, especially if older than 35 years? • Do any family members have an intellectual disability or developmental delays? • Do any family members have a known or suspected metabolic disorder such as PKU? • What is the maternal age of both parents presently with this pregnancy? • Do any family members have an affective disorder such as bipolar disorder? • Have any close relatives been diagnosed with any type of cancer? • What is your ethnic background (explore as related to certain disorders)? • Do any family members have a known or suspected chromosomal disorder? • Do any family members have a progressive neurologic disorder? Adapted from Edelman, C. L., Kudzma, E. C., & Mandle, C. L. (2014). Health promotion throughout the lifespan (8th ed.). St. Louis, MO: Mosby Elsevier; Snustad, D.P. (2015). Principles of genetics (7th ed.). New York, NY: Wiley Publishers; Latendresse, G. & Deneris, A. (2015). An update on current prenatal testing options: First trimester and noninvasive prenatal testing. Journal of Midwifery & Women’s Health, 60(1), 24–36; and Genetic Alliance.(2015). Family health history. Retrieved from http://geneticalliance.org/programs/genesinlife/fhh

Talking with family members who have recently been diagnosed with a genetic disorder or who have had a child born with congenital anomalies is very difficult. Many times the nurse may be the one who has first contact with these parents and will be the one to provide follow-up care. Genetic disorders are significant, life-changing, and possibly life-threatening situations. Genetic information is highly technical and the field is undergoing significant technological advances. Nurses need an understanding of who will benefit from genetic counseling and must be able to discuss the role of the genetic counselor with families. The goal is to ensure that families at risk are aware that genetic counseling is available before they attempt to have another baby. Based on the results of their genetic tests, Robert and Kate are placed at moderate risk for having an infant with an autosomal recessive genetic disorder. The couple asks the nurse what all of this means. What information should the nurse provide about concepts of probability and disorder susceptibility for this couple? How can the nurse help this couple to make knowledgeable decisions concerning their reproductive future? Nurses play an essential role in providing emotional support to the family through this challenging time. Genetics permeates all aspects of health care. Today, everyone is embracing quality and evidence-based care. Nurses who have an understanding of genetics and genomics will possess the foundation to provide quality, evidence-based care especially with follow-up counseling after the couple or family has been to the genetic specialist.

Take Note! Nurses need to be actively engaged with clients and their families and help them consider the facts, values, and context in which they are making decisions. Nurses need to be open and honest with families as they discuss these sensitive and emotional choices. Nurses should provide ongoing support and education for clients and their families. This includes coping with the disease burden, helping clients and families adapt to a condition in the family, and ensuring adequate understanding

of the genetic risks and the available prenatal diagnostic and reproductive choices. The nurse is in an ideal position to help families review what has been discussed during the genetic counseling sessions and to answer any additional questions they might have. Referral to appropriate agencies, support groups, and resources, such as a social worker, a chaplain, or an ethicist, is another key role when caring for families with suspected or diagnosed genetic disorders. KEY CONCEPTS Fertilization, which takes place in the outer third of the ampulla of the fallopian tube, leads to the formation of a zygote. The zygote undergoes cleavage, eventually implanting in the endometrium about 7 to 10 days after conception. Three embryonic layers of cells are formed: ectoderm, which forms the central nervous system, special senses, skin, and glands; mesoderm, which forms the skeletal, urinary, circulatory, and reproductive systems; and endoderm, which forms the respiratory system, liver, pancreas, and digestive system. Amniotic fluid surrounds the embryo and increases in volume as the pregnancy progresses, reaching approximately a liter by term. At no time during pregnancy is there any direct connection between the blood of the fetus and the blood of the mother, so there is no mixing of blood. The placenta protects the fetus from immune attack by the mother, removes waste products from the fetus, induces the mother to bring more food to the placenta, and, near the time of delivery, produces hormones that mature fetal organs in preparation for life outside the uterus. The purpose of fetal circulation is to carry highly oxygenated blood to vital areas (heart and brain) while first shunting it away from less vital ones (lungs and liver). Humans have 46 paired chromosomes that are found in all cells of the body, except the ovum and sperm cells, which have just 23 chromosomes. Each person has a unique genetic constitution, or genotype. Research from the HGP has provided a better understanding of the genetic contribution to disease. Genetic disorders can result from abnormalities in patterns of inheritance or chromosomal abnormalities involving chromosomal number or structure.

Autosomal dominant inheritance occurs when a single gene in the heterozygous state is capable of producing the phenotype. Autosomal recessive inheritance occurs when two copies of the mutant or abnormal gene in the homozygous state are necessary to produce the phenotype. X-linked inheritance disorders are those associated with altered genes present on the X chromosome. They can be dominant or recessive. In some cases of genetic disorders, a chromosomal abnormality occurs. Chromosomal abnormalities do not follow straightforward patterns of inheritance. These abnormalities occur on autosomal as well as sex chromosomes and can result from changes in the number of chromosomes or changes in the structure of the chromosomes. Genetic counseling involves evaluation of an individual or a family. Its purpose is to confirm, diagnose, or rule out genetic conditions, identify medical management issues, calculate and communicate genetic risks to a family, discuss ethical and legal issues, and assist in providing and arranging psychosocial support. Legal, ethical, and social issues that can arise related to genetic testing include the privacy and confidentiality of genetic information, who should have access to personal genetic information, psychological impact and stigmatization due to individual genetic differences, use of genetic information in reproductive decision making and reproductive rights, and whether testing is to be performed if no cure is available. Preconception screening and counseling can raise serious ethical and moral issues for a couple. The results of prenatal genetic testing can lead to the decision to terminate a pregnancy. Nurses play an important role in beginning the preconception counseling process and referring women and their partners for further genetic information when indicated. Many times the nurse is the one who has first contact with these women and will be the one to provide follow-up care. Nurses need to have a solid understanding of who will benefit from genetic counseling and must be able to discuss the role of the genetic counselor with families, ensuring that families at risk are aware that genetic counseling is available before they attempt to have another baby. Nurses play an essential role in providing emotional support and referrals to appropriate agencies, support groups, and resources when caring for families

with suspected or diagnosed genetic disorders. Nurses can assist clients with their decision making by referring them to a social worker, a chaplain, or an ethicist.

References and Recommended Readings American Heart Association [AHA]. (2015). Fetal circulation. Retrieved from

https://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/SymptomsDiagnosisofCongenitalHeartDefects/Fe Circulation_UCM_315674_Article.jsp Association of Genetic Nurses and Counselors [AGNC]. (2015). Getting the message across. Retrieved from http://www.agnc.org.uk/news-events/news/ Centers for Disease Control and Prevention [CDC]. (2015a). Facts about birth defects. Retrieved from http://www.cdc.gov/ncbddd/birthdefects/facts.html Centers for Disease Control and Prevention [CDC]. (2015b). Facts about Down syndrome. Retrieved from http://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html Centers for Disease Control and Prevention [CDC]. (2015c). Fragile X syndrome: Data & statistics. Retrieved from http://www.cdc.gov/ncbddd/fxs/data.html Chen, H. (2015a). Cri du chat syndrome. eMedicine. Retrieved from http://emedicine.medscape.com/article/942897-overview Chen, H. (2015b). Klinefelter syndrome. eMedicine. Retrieved from http://emedicine.medscape.com/article/945649-overview Cicalese, M. P., & Aiuti, A. (2015). Clinical applications of gene therapy for primary immunodeficiencies. Human Gene Therapy, 26(4), 210–219. Dayal, M. B., & Athanasiadis, I. (2015). Preimplantation genetic diagnosis. eMedicine. Retrieved from http://emedicine.medscape.com/article/273415-overview#aw2aab6b3 Dutta, S. (2015). Human teratogens and their effects: A critical evaluation. International Journal of Informative Research and Review, 2(3), 525–536. Edelman, C. L., Kudzma, E.C., & Mandle, C. L. (2014). Health promotion throughout the lifespan (8th ed.). St. Louis, MO: Mosby Elsevier. El-Mazny, A. (2014). Human reproduction: Basic anatomy and physiology. Charleston, SC: Amazon CreateSpace Publishers. Farrell, R. M., Nutter, B., & Agatisa, P. K. (2015). Patient-centered prenatal counseling: Aligning obstetric healthcare professionals with needs of pregnant women. Women & Health, 55(3), 280–296. Fisher, S. (2015). Placenta: The forgotten organ. Annual Review of Cell and Developmental Biology, 31(1), 523–552 Retrieved from http://www.annualreviews.org/doi/abs/10.1146/annurev-cellbio-100814-125620 Finnemore, A., & Groves, A. (2015). Physiology of the fetal and transitional circulation. Seminars in Fetal and Neonatal Medicine, 20(4), 210–216 (Online 4/24/15). Freemark, M. (2015). Placental hormones and the control of fetal growth. International Journal of Pediatric Endocrinology, 2015(Suppl 1), O13. d

Genetic Alliance. (2015). Family health history. Retrieved from http://geneticalliance.org/programs/genesinlife/fhh Grieco, J., Pulsifer, M., Seligsohn, K., Skotko, B., & Schwartz, A. (2015). Down syndrome: Cognitive and behavioral functioning across the lifespan. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 1–15. International Human Genome Sequencing Consortium. (2015). Celebrating a decade of discovery since the Human Genome project. Retrieved from http://genome.wellcome.ac.uk/doc_WTX060109.html International Society of Nurses in Genetics [ISONG]. (2015). What can genetics nurses do for you? Retrieved from http://www.isong.org/ISONG_genetic_nurse.php Johannesson, B., Sui, L., Freytes, D. O., Creusot, R. J., & Egli, D. (2015). Toward beta cell replacement for diabetes. The Excellence in the Life Sciences Journal (EMBO), 34(7), 841–855. Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.). Waltham, MA: Elsevier. Jordan, R. G., Engstrom, J., Marfell, J., & Farley, C. L. (2014). Prenatal and postnatal care: A womancentered approach. Ames, Iowa: Wiley Blackwell Khalil, A., & Coates, A. (2015). Prenatal diagnosis of chromosomal abnormalities. Arias’ practical guide to high-risk pregnancy and delivery: A South Asian perspective, (4th ed., pp. 1–13). Haryana, India: Elsevier King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, MA: Jones & Bartlett Learning. Kumar, A., Ryan, A., Kitzman, J. O., Wemmer, N., Snyder, M. W., Sigurjonsson, S., et al. (2015). Whole genome prediction for preimplantation genetic diagnosis. Genome Medicine, 7(1), 35. Kumar, S., Kingsley, C., & DiStefano, J. K. (2015). The Human Genome Project: Where are we now and where are we going?. Genome mapping and genomics in human and non-human primates (pp. 7–31). Berlin Heidelberg: Springer Publishers. Kuppermann, M., Pena, S., Bishop, J. T., Nakagawa, S., Gregorich, S. E., Sit, A., et al. (2015). Effect of enhanced information, values clarification, and removal of financial barriers on use of prenatal genetic testing: A randomized clinical trial. Obstetrical & Gynecological Survey, 70(1), 7–9. Latendresse, G., & Deneris, A. (2015). An update on current prenatal testing options: First trimester and noninvasive prenatal testing. Journal of Midwifery & Women’s Health, 60(1), 24–36. Lea, D. H., Cheek, D., Brazeau, D., & Brazeau, G. (2015). Pharmacogenomics/pharmacogenetics and interprofessional education and practice. Mastering pharmacogenomics: A nurse’s handbook for success (pp. 191–204). Indianapolis, IN: Sigma Theta Tau International. Lundstrom, K. (2015). New era in gene therapy. Novel approaches and strategies for biologics, vaccines and cancer therapies, (pp. 15–40). San Diego, CA: Elsevier. Lopes, L. C., de Omena Bomfim, E., & Flória-Santos, M. (2015). Genomics-based health care: Implications for nursing. International journal of Nursing Didactics, 5(02), 11–15.

Mader, S., & Windelspecht, M. (2015). Human biology (14th ed.). New York, NY: McGraw-Hill Higher Education Maeda, K. (2015). Prenatal fetal life in the mother. Journal of Health & Medical Informatics, 6, 177. March of Dimes. (2015a). Chromosomal abnormalities. Retrieved from http://www.marchofdimes.com/hbhb_syndication/15530_1209.asp March of Dimes. (2015b). Down syndrome. Retrieved from http://www.marchofdimes.com/baby/downsyndrome.aspx# March of Dimes. (2015c). How your baby grows. Retrieved from http://www.marchofdimes.com/pregnancy/how-your-baby-grows.aspx# March of Dimes. (2015d). Genetic counseling. Retrieved from http://www.marchofdimes.com/pregnancy/genetic-counseling.aspx Moore, T. R. (2015). Abnormal amniotic fluid. Protocols for high-risk pregnancies: An evidence-based approach, (6th ed., pp. 315–328). Oxford, UK: John Wiley & Sons. Mueller, W. A., Hassel, M., & Grealy, M. (2015). The human. Development and reproduction in humans and animal model species (pp. 169–213). Berlin Heidelberg: Springer Publishers. National Down Syndrome Society [NDSS]. (2015a). What is Down syndrome? Retrieved from https://www.ndss.org/Down-Syndrome/What-Is-Down-Syndrome/ National Down Syndrome Society [NDSS]. (2015b). Myths and truths about Down syndrome. Retrieved from http://www.ndss.org/Down-Syndrome/Myths-Truths/ National Human Genome Research Institute. (2015). What is genetic counseling and evaluation? Retrieved from https://www.genome.gov/19016905 National Institutes of Health [NIH]. (2015a). Mutations and health. Retrieved from http://ghr.nlm.nih.gov/handbook/mutationsanddisorders National Institutes of Health [NIH]. (2015b). Turner syndrome. Retrieved from http://ghr.nlm.nih.gov/condition/turner-syndrome National Organization for Rare Disorders [NORD]. (2015a). Trisomy 18 syndrome. Retrieved from https://www.rarediseases.org/rare-disease-information/rare-diseases/byID/217/viewAbstract National Organization for Rare Disorders [NORD]. (2015b). Trisomy 13 syndrome. Retrieved from https://www.rarediseases.org/rare-disease-information/rare-diseases/byID/218/viewAbstract National Organization for Rare Disorders [NORD]. (2015c). Turner syndrome. Retrieved from https://www.rarediseases.org/rare-disease-information/rare-diseases/byID/112/viewAbstract National Organization for Rare Disorders [NORD]. (2015d). Cri du chat syndrome. Retrieved from http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Cri%20du%20Chat%20Syndrome National Organization for Rare Disorders [NORD]. (2015e). Fragile X syndrome. Retrieved from http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Fragile%20X%20Syndrome National Organization for Rare Disorders [NORD]. (2015f). Klinefelter syndrome. Retrieved from

http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Klinefelter%20Syndrome Sermon, K., & Viville, S. (2014). Textbook of human reproductive genetics. New York, NY: Cambridge University Press. Snustad, D. P. (2015). Principles of genetics (7th ed.). New York, NY: Wiley Publishers. Support Organization for Trisomies [SOFT]. (2015). Trisomy 13 facts. Retrieved from http://trisomy.org/trisomy-13-facts-2/ Travers, A., & Muskhelishvili, G. (2015). DNA structure and function. Federation of European Biochemical Societies (FEBS) Journal, 282(12), 2279–2295. Trisomy 18 Foundation. (2015). What is Trisomy 18? Retrieved from http://www.trisomy18.org/site/PageServer?pagename=whatisT18_whatis Wilson, B. J., & Nicholls, S. G. (2015). The Human Genome Project, and recent advances in personalized genomics. Risk Management and Healthcare Policy, 8, 9–20. Yudkowitz, F. S. (2015). Fetal-neonatal physiology and circulation. Obstetric anesthesia (pp. 17–23). New York, NY: McGraw-Hill Education. Zhang, L., & Ducsay, C. A. (2014). Advances in fetal and neonatal physiology. New York, NY: Spring Publishers.

CHAPTER WORKSHEET MULTIPLE-CHOICE QUESTIONS 1. After teaching a group of students about fertilization, the instructor determines that the teaching was successful when the group identifies which as the usual site of fertilization? a. Fundus of the uterus b. Endometrium of the uterus c. Upper portion of fallopian tube d. Follicular tissue of the ovary 2. Working in a reproductive health services clinic, the nurse is aware that the goal of the Human Genome project was to: a. Link specific abnormal genes to specific diseases for better treatment b. Map, sequence, and determine the function of all human genes c. Understand the underlying causes of diseases to transform health care

d. Measure the impact of certain chromosomes on disease prevention 3. The nurse is counseling a couple, one of whom is affected by an autosomal dominant disorder. They express concerns about the risk of transmitting the disorder. What is the best response by the nurse regarding the risk that their baby may have the disease? a. “You have a one in four (25%) chance.” b. “The risk is 12.5%, or a one in eight chance.” c. “The chance is 100%.” d. “Your risk is 50%, or a one in two chance.” 4. What is the first step in determining a couple’s risk for a genetic disorder? a. Observing the client and family over time b. Conducting extensive psychological testing c. Obtaining a thorough family health history d. Completing an extensive exclusionary list 5. A nurse is working in a women’s health clinic. Genetic counseling would be most appropriate for the woman who: a. Just had her first miscarriage at 10 weeks b. Is 30 years old and planning to conceive c. Has a history with a close relative with Down syndrome d. Is 18 weeks pregnant with a normal triple screen result 6. Klinefelter syndrome is caused by a nondisjunction resulting in a genotype of: a. YYY b. XYY c. XXX d. XXY 7. Down syndrome results from the: a. Absence of one chromosome in position 21 b. Presence of an extra chromosome in position 21

c. Absence of both chromosomes in position 21 d. Crossing over of the chromosomes in position 21

CRITICAL THINKING EXERCISE 1. Mr. and Mrs. Martin wish to start a family, but they can’t agree on something important: Mr. Martin wants his wife to be tested for cystic fibrosis (CF) to see if she is a carrier. Mr. Martin had a brother with CF and watched his parents struggle with the hardship and the expense of caring for him for years, and he doesn’t want to experience it in his own life. Mr. Martin has found out he is a CF carrier. Mrs. Martin doesn’t want to have the test because she figures that once a baby is in their arms, they will be glad, no matter what. a. What information/education should this couple consider before deciding whether to have the test? b. How can you assist this couple in their decision-making process? c. What is your role in this situation if you don’t agree with their decision?

STUDY ACTIVITIES 1. Obtain the video Miracle of Life, which shows conception and fetal development. What are your impressions? Is the title of this video realistic? 2. Select one of the websites from the extensive list of websites provided on to explore the topic of genetics. Critique the information presented. Was it understandable to a layperson? What specifically did you learn? Share your findings with your classmates during a discussion group. 3. Draw your own family pedigree, identifying inheritance patterns. Share it with your family to validate its accuracy. What did you discover about your family’s past health? 4. Select one of the various prenatal screening tests (alpha-fetoprotein, amniocentesis, chorionic villus sampling, or fetal nuchal translucency) and research it in depth. Role-play with another nursing student how you would explain its purpose, the procedure, and potential findings to an expectant couple at risk for a fetal abnormality.

BRINGING IT ALL TOGETHER: CASE STUDY A 27-year-old female of African-American descent presents to the preconception care clinic with her husband. They have been married for 2 years and are planning a pregnancy. They want to know about sickle cell anemia and other hemoglobin abnormalities. They ask if prenatal tests exist for this condition, and if they can be tested to determine their carrier status. They also want to understand the risks related to their future offspring if they are carriers. They have known several people with sickle cell anemia at their church and wonder if everyone with this disorder is affected the same way.

ASSESSMENT A family history is taken by the nurse to determine if any of the couple’s relatives have this disease or manifestations of it. They may not be aware of the various manifestations of it, but can describe behaviors and observations of their various family members. An explanation of the screening procedure to determine if they are carriers of the sickle cell trait is then offered. Go to

to find questions to consider about this case.

11 Maternal Adaptation During Pregnancy

KEY TERMS ballottement Braxton Hicks contractions Chadwick’s sign dietary reference intakes (DRIs) Goodell’s sign Hegar’s sign linea nigra physiologic anemia of pregnancy pica quickening trimester

Learning Objectives Upon completion of the chapter, you will be able to: 1. Differentiate between subjective (presumptive), objective (probable), and diagnostic (positive) signs of pregnancy. 2. Describe maternal physiologic changes that occur during pregnancy. 3. Summarize the nutritional needs of the pregnant woman and her fetus. 4. Characterize the emotional and psychological changes that occur during pregnancy. Marva, age 17, appeared at the health department clinic complaining that she had a stomach virus and needed to be seen right away. When the nurse asked her additional questions about her illness, Marva reported that she had been sick to her stomach and “beat tired” for days. She had stopped eating to avoid any more nausea and vomiting.

Words of Wisdom When a woman discovers that she is pregnant, she must remember to protect and nourish the fetus by making wise choices.

INTRODUCTION Pregnancy is a normal life event that involves considerable physical and psychological adjustments for the mother. A pregnancy is divided into three trimesters of 13 weeks each (Edelman, Kudzma, & Mandle, 2014). Within each trimester, numerous adaptations take place that facilitate the growth of the fetus. The most obvious are physical changes to accommodate the growing fetus, but pregnant women also undergo psychological changes as they prepare for parenthood. A thorough understanding of these numerous changes and adaptations is essential for all nurses caring for women during pregnancy.

SIGNS AND SYMPTOMS OF PREGNANCY Traditionally, signs and symptoms of pregnancy have been grouped into the following categories: presumptive, probable, and positive (Box 11.1). The only signs that can determine a pregnancy with 100% accuracy are positive signs. What additional information is necessary to complete the assessment of Marva, the 17-year-old with nausea and vomiting? What diagnostic tests might be done to confirm the nurse’s suspicion that she is pregnant?

Subjective (Presumptive) Signs Presumptive signs are those signs that the mother can perceive. The most obvious presumptive sign of pregnancy is the absence of menstruation. Skipping a period is not a reliable sign of pregnancy by itself, but if it is accompanied by consistent nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would seem very likely. Presumptive changes are the least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy (Shields, 2015). For example, amenorrhea can be caused by early menopause, endocrine dysfunction, malnutrition, anemia, diabetes mellitus, long-distance running, cancer, or stress. Nausea and vomiting can be caused by gastrointestinal disorders, food poisoning, acute infections, or eating disorders. Fatigue could be caused by anemia, stress, or viral infections. Breast tenderness may result from chronic cystic mastitis, premenstrual changes, or the use of oral contraceptives. Urinary frequency could have a variety of causes other than pregnancy, such as infection, cystocele, structural disorders, pelvic tumors, or emotional tension (Tharpe et al., 2016).

Consider This

Jim and I decided to start our family, so I stopped taking the pill 3 months ago. One morning when I got out of bed to take the dog out, I felt queasy and light-headed. I sure hoped I was not coming down with the flu. By the end of the week, I was feeling really tired and started taking naps in the afternoon. In addition, I seemed to be going to the bathroom frequently, despite not drinking much fluid. When my breasts started to tingle and ache, I decided to make an appointment with my doctor to see what “illness” I had contracted. After listening to my list of physical complaints, the office nurse asked me if I might be pregnant. My eyes opened wide: I had somehow missed the link between my symptoms and pregnancy. I started to think about when my last period was, and it had been 2 months ago. The office ran a pregnancy test and much to my surprise it was positive!

Thoughts: Many women stop contraceptives in an attempt to achieve pregnancy but miss the early signs of pregnancy. This woman was experiencing several signs of early pregnancy—urinary frequency, fatigue, morning nausea, and breast tenderness. What advice can the nurse give this woman to ease these symptoms? What additional education related to her pregnancy would be appropriate at this time?

BOX 11.1 SIGNS AND SYMPTOMS OF PREGNANCY

Objective (Probable) Signs Physical Signs Probable signs of pregnancy are those that can be detected on physical examination by a health care provider. Common probable signs of pregnancy include softening of the lower uterine segment or isthmus (Hegar’s sign), softening of the cervix (Goodell’s sign), and a bluish-purple coloration of the vaginal mucosa and cervix (Chadwick’s sign). Other probable signs include changes in the shape and size of the uterus, abdominal enlargement, Braxton Hicks contractions, and ballottement (the examiner pushes against the woman’s cervix during a pelvic examination and feels a rebound from the floating fetus).

Pregnancy Tests Along with these physical signs, pregnancy tests are also considered a probable sign of pregnancy. In-home pregnancy testing became available in the United States in late 1977. In-home testing appealed to the general public because of convenience, cost, and confidentiality. Several pregnancy tests are available (Table 11.1). The tests vary in sensitivity, specificity, and accuracy and are influenced by the length of gestation, specimen concentration, presence of blood, and the presence of some drugs. Human chorionic gonadotropin (hCG) is detectable in the serum of approximately 5% of clients 8 days after conception and in more than 98% of clients by day 11 (Shields, 2015). At least 25 different home pregnancy tests are currently marketed in the United States. Most of these tests claim “99% accuracy” according to a U.S. Food and Drug Administration (FDA) guideline or make other similar statements on the packaging or product insert. The 99% accuracy statement in reference to the FDA guideline is misleading in that it has no bearing on the ability of the home pregnancy test to detect early pregnancy (Shields, 2015). The limitations of these tests must be understood so that pregnancy detection is not delayed significantly. Early pregnancy detection allows for the commencement of prenatal care, potential medication changes, and lifestyle changes to promote a healthy pregnancy. TABLE 11.1 SELECTED PREGNANCY TESTS

hCG is a glycoprotein and the earliest biochemical marker for pregnancy. Many pregnancy tests are based on the recognition of hCG or a beta subunit of hCG. hCG levels in normal pregnancy usually double every 48 to 72 hours until they peak approximately 60 to 70 days after fertilization. At this point, they decrease to a plateau at 100 to 130 days of pregnancy. The hCG doubling time has been used as a marker by clinicians to differentiate normal from abnormal gestations. Low levels are associated with an ectopic pregnancy and higher-thannormal levels may indicate a molar pregnancy or multiple-gestational pregnancies (Zinaman, Johnson, & Marriott, 2015).

Take Note! This elevation of hCG corresponds to the morning sickness period of approximately 6 to 12 weeks during early pregnancy. Although probable signs suggest pregnancy and are more reliable than presumptive signs, they still are not 100% reliable in confirming a pregnancy. For example, uterine tumors, polyps, infection, and pelvic congestion can cause changes to uterine shape, size, and consistency. And although pregnancy tests are used to establish the diagnosis of pregnancy when the physical signs are still inconclusive, they are not completely reliable, because conditions other than pregnancy (e.g., ovarian cancer, choriocarcinoma, hydatidiform mole) can also elevate hCG levels.

Positive Signs Usually within 2 weeks after a missed period, enough subjective symptoms are present so that a woman can be reasonably sure she is pregnant. However, an experienced health care provider can confirm her suspicions by identifying positive signs of pregnancy that can be directly attributed to the fetus. The positive signs of pregnancy confirm that a fetus is growing in the uterus. Visualizing the fetus by ultrasound, palpating for fetal movements, and hearing a fetal heartbeat are all signs that make the pregnancy a certainty. If the pregnancy test is positive, the clinical visit should include an estimation of gestational age so that appropriate counseling can be provided. In addition, clients should receive information about the normal signs and symptoms of early pregnancy, and should be instructed to report any concerns to the health care provider for further evaluation. Once pregnancy has been confirmed, the health care provider will set up a schedule of prenatal visits to assess the woman and her fetus throughout the entire pregnancy. Assessment and education begins at the first visits and continues throughout the pregnancy (see Chapter 12). Remember Marva, who thought she had a stomach virus? Her pregnancy test was positive. On questioning by the nurse, she acknowledged missing two menstrual periods and being sexually active with her boyfriend without using protection. What is the nurse’s role at this point with Marva? What instructions might be given to her while she waits for her first prenatal visit?

PHYSIOLOGIC ADAPTATIONS DURING PREGNANCY Every system of a woman’s body changes during pregnancy to accommodate the needs of the growing fetus, and these changes occur with startling rapidity. The physical changes of pregnancy can be uncomfortable, although every woman reacts uniquely.

Reproductive System Adaptations Significant changes occur throughout the woman’s body during pregnancy to accommodate the growing human being within her. Many have a protective role for maternal homeostasis and are essential to meet the demands of both the mother and the fetus. Many adaptations are reversible after the woman gives birth, but some persist for life.

Uterus The uterus grows at a steady and predictable rate during pregnancy. During the first few months of pregnancy, estrogen stimulates uterine growth, and the uterus undergoes a tremendous increase in size, weight, length, width, depth, volume, and overall capacity throughout pregnancy. The weight of the uterus increases from 70 g to about 1,100 to 1,200 g at term; its capacity increases from 10 to 5,000 mL or more at term (King et al., 2015). The uterine walls thin to 1.5 cm or less; the shape changes from pear shape to a solid globe in the first trimester, and then expands to become a hollow vessel. Uterine growth occurs as a result of both hyperplasia and hypertrophy of the myometrial cells, which do not increase much in number but do increase in size. In early pregnancy, uterine growth is due to hyperplasia of uterine smooth muscle cells within the myometrium; however, the major component of myometrial growth occurs after mid-gestation due to smooth muscle cell hypertrophy caused by mechanical stretch of uterine tissue by the growing fetus (Osol & Moore, 2014). Blood vessels elongate, enlarge, dilate, and sprout new branches to support and nourish the growing muscle tissue, and the increase in uterine weight is accompanied by a large increase in uterine blood flow, which is necessary to perfuse the uterine muscle and accommodate the growing fetus. As pregnancy progresses, 80% to 90% of uterine blood flow goes to the placenta, with the remainder distributed between the endometrium and myometrium. During pregnancy, the diameter of the main uterine artery approximately doubles in size. This enlargement from a narrow to a larger-caliber vessel enhances the capacity of the uteroplacental vessels to accommodate the increased blood volume needed to supply the placenta (Osol & Moore, 2014). Uterine contractility is enhanced as well. Spontaneous, irregular, and painless contractions, called Braxton Hicks contractions, begin during the first

trimester. These contractions continue throughout pregnancy, becoming especially noticeable during the last month, when they function to thin out or efface the cervix before birth (see Chapter 12 for more information). The lower portion of the uterus (the isthmus) does not undergo hypertrophy and becomes increasingly thinner as pregnancy progresses, thereby forming the lower uterine segment. Changes in the lower uterus occurring during the first 6 to 8 weeks of gestation produce some of the typical findings, including a positive Hegar’s sign. This softening and compressibility of the lower uterine segment results in exaggerated uterine anteflexion during the early months of pregnancy, which adds to urinary frequency (Heffner & Schust, 2014). The uterus remains in the pelvic cavity for the first 3 months of pregnancy, after which it progressively ascends into the abdomen (Fig. 11.1). As the uterus grows, it presses on the urinary bladder and causes the increased frequency of urination experienced during early pregnancy. In addition, the heavy gravid uterus in the last trimester can fall back against the inferior vena cava in the supine position, resulting in vena cava compression, which reduces venous return and decreases cardiac output and blood pressure, with increasing orthostatic stress. This occurs when the woman changes her position from recumbent to sitting to standing. This acute hemodynamic change, termed supine hypotensive syndrome, causes the woman to experience symptoms of weakness, light-headedness, nausea, dizziness, or syncope (Fig. 11.2). These changes are reversed when the woman is in the side-lying position, which displaces the uterus to the left and off the vena cava.

FIGURE 11.1 The growing uterus in the abdomen.

FIGURE 11.2 Supine hypotensive syndrome.

The uterus, which starts as a pear-shaped organ, becomes ovoid as length increases over width. By 20 weeks’ gestation, the fundus, or top of the uterus, is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number

of gestational weeks, is commonly used to date the pregnancy.

Take Note! Fundal height usually can be correlated with gestational weeks most accurately between 18 and 32 weeks. Obesity, hydramnios, and uterine fibroids interfere with the accuracy of this correlation. The fundus reaches its highest level, at the xiphoid process, at approximately 36 weeks. Between 38 and 40 weeks, fundal height drops as the fetus begins to descend and engage into the pelvis. Because it pushes against the diaphragm, many women experience shortness of breath. By 40 weeks, the fetal head begins to descend and engage in the pelvis, which is termed lightening. For the woman who is pregnant for the first time, lightening usually occurs approximately 2 weeks before the onset of labor; for the woman who is experiencing her second or subsequent pregnancy, it usually occurs at the onset of labor. Although breathing becomes easier because of this descent, the pressure on the urinary bladder now increases and the woman now experiences urinary frequency again, as she did in the first trimester of pregnancy.

Cervix Between weeks 6 and 8 of pregnancy, the cervix begins to soften (Goodell’s sign) due to vasocongestion and the influence of estrogen. Along with the softening, the endocervical glands increase in size and number and produce more cervical mucus. Under the influence of progesterone, a thick mucus plug is formed that blocks the cervical os and protects the opening from bacterial invasion. At about the same time, increased vascularization of the cervix causes Chadwick’s sign, a cyanosis or bluish purple discoloration Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. The connective tissues of the cervix undergo biochemical modifications in preparation for labor that result in changes to its elasticity and strength. These changes are mediated through several factors, including inflammation, cervical stretch, pressure of the fetal presenting part, and release of hormones, including oxytocin, relaxin, nitric oxide, and prostaglandins (Myers et al., 2015).

Vagina During pregnancy, vascularity increases because of the influences of estrogen, resulting in pelvic congestion and hypertrophy of the vagina in preparation for the distention needed for birth. The vaginal mucosa thickens, the connective tissue begins to loosen, the smooth muscle begins to hypertrophy, and the vaginal vault begins to lengthen (Bope & Kellerman, 2015). Vaginal secretions become more acidic, white, and thick. Most women experience an increase in a whitish vaginal discharge, called leukorrhea, during pregnancy. This is normal except when it is accompanied by itching and irritation, possibly suggesting Candida albicans, a monilial vaginitis, which is a very common occurrence in this glycogen-rich environment (King et al., 2015). Symptomatic vulvovaginal candidiasis affects 15% of pregnant women (Krapf, 2015). It is a benign fungal condition that is uncomfortable for the woman and can be transmitted from an infected mother to her newborn at birth. Neonates develop an oral infection known as thrush, which presents as white patches on the mucous membranes of their mouths. It is self-limiting and is treated with local antifungal agents.

Ovaries The increased blood supply to the ovaries causes them to enlarge until approximately the 12th to 14th week of gestation. The ovaries are not palpable after that time because the uterus fills the pelvic cavity. Ovulation ceases during pregnancy because of the elevated levels of estrogen and progesterone, which block secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. The ovaries are very active in hormone production to support the pregnancy until about weeks 6 to 7, when the corpus luteum regresses and the placenta takes over the major production of progesterone.

Breasts The breasts increase in fullness, become tender, and grow larger throughout pregnancy under the influence of estrogen and progesterone. The breasts become highly vascular and veins become visible under the skin. The nipples become larger and more erect. Both the nipples and the areola become deeply pigmented, and tubercles of Montgomery (sebaceous glands) become prominent. These sebaceous glands keep the nipples lubricated for breast-feeding.

Changes that occur in the connective tissue of the breasts, along with the tremendous growth, lead to striae (stretch marks) in approximately half of all pregnant women (Jordan et al., 2014). Initially they appear as pink to purple lines on the skin, but they eventually fade to a silver color. Although they become less conspicuous in time, they never completely disappear. Creamy, yellowish breast fluid called colostrum can be expressed from the breast, if squeezed, by the third trimester. This fluid provides nourishment for the breast-feeding newborn during the first few days of life (see Chapters 15 and 16 for more information). Table 11.2 summarizes reproductive system adaptations.

General Body System Adaptations In addition to changes in the reproductive system, the pregnant woman also experiences changes in virtually every other body system in response to the growing fetus.

Gastrointestinal System The gastrointestinal system begins in the oral cavity and ends at the rectum. During pregnancy, the gums become hyperemic, swollen, and friable and tend to bleed easily. This change is influenced by estrogen and increased proliferation of blood vessels and circulation to the mouth. In addition, the saliva produced in the mouth becomes more acidic. Some women complain about excessive salivation, termed ptyalism, which may be caused by the decrease in unconscious swallowing by the woman when nauseated. Ptyalism typically resolves spontaneously, although in some women it endures throughout the pregnancy. Some women get temporary relief from gum chewing or sucking on hard candies (King et al., 2015). Dental plaque, calculus, and debris deposits increase during pregnancy and are all associated with gingivitis. An increased production of female hormones during pregnancy contributes to the development of gingivitis and periodontitis because vascular permeability and possible tissue edema are both increased. It is reported that as many as 50% to 70% of pregnant women will have some level of gingivitis during pregnancy as a result of hormonal changes that promote inflammation (Anil et al., 2015). Previous studies linked periodontal disease with preterm birth; preeclampsia, and lowbirth-weight risk, stillbirth and early-onset neonatal sepsis, but more recent research findings indicated no reduction in preterm births with the treatment of periodontal disease during pregnancy (Trivedi, Lal, & Singhal, 2015). TABLE 11.2 SUMMARY OF REPRODUCTIVE SYSTEM ADAPTATIONS

Concept Mastery Alert Gum Fragility in Pregnancy Bleeding of gums during pregnancy, results from increased estrogen levels that cause blood vessel proliferation. This then leads to increased blood vessels in the gums and an increased chance of bleeding.

Smooth muscle relaxation and decreased peristalsis occur related to the influence of progesterone. Elevated progesterone levels cause smooth muscle relaxation, which results in delayed gastric emptying and decreased peristalsis. Transition time of food throughout the gastrointestinal tract may be so much slower that more water than normal is reabsorbed, leading to bloating and constipation. Constipation can also result from low-fiber food choices, reduced fluid intake, use of iron supplements, decreased activity level, and intestinal displacement secondary to a growing uterus. Constipation, increased venous pressure, and the pressure of the gravid uterus contribute to the formation of hemorrhoids. The slowed gastric emptying combined with relaxation of the cardiac

sphincter allows reflux, which causes heartburn. Acid indigestion or heartburn (pyrosis) seems to be a universal problem for pregnant women. It is caused by regurgitation of the stomach contents into the upper esophagus and may be associated with the generalized relaxation of the entire digestive system. Overthe-counter antacids will usually relieve the symptoms, but they should be taken with the health care provider’s knowledge and only as directed. The emptying time of the gallbladder is prolonged secondary to the smooth muscle relaxation from progesterone. Hypercholesterolemia can follow, increasing the risk of gallstone formation. Other risk factors for gallbladder disease include obesity, Hispanic ethnicity, and increasing maternal age (Heuman, Mihas, & Allen, 2015). Nausea and vomiting, better known as morning sickness, plague about 80% of pregnant women. This condition is usually self-limiting, but the symptoms can be distressing and interfere with work, social activities, and interrupt sleep. Recently, the FDA approved doxylamine succinate 10 mg/pyridoxine hydrochloride 10 mg (Diclegis) as the first medication to specifically treat morning sickness in pregnancy (Pope, Maltepe, & Koren, 2015). Although it occurs most often in the morning, the nauseated feeling can last all day in some women. The highest incidence of morning sickness occurs between 6 and 12 weeks. The physiologic basis for morning sickness is still debatable. It has been linked to the high levels of hCG, high levels of circulating estrogens, prostaglandins, reduced stomach acidity, advancing maternal age, slowed peristalsis, genetic factors, and the lowered tone and motility of the digestive tract (King et al., 2015).

Cardiovascular System Cardiovascular changes occur early during pregnancy to meet the demands of the enlarging uterus and the placenta for more blood and more oxygen. The changes include an increase in heart rate (25%); cardiac output increases by 30% to 50% and peaks at 25 to 30 weeks gestation; reduced total peripheral resistance; increased blood volume; increased plasma volume which leads to physiologic anemia. Perhaps the most striking cardiac alteration occurring during pregnancy is the increase in blood volume. BLOOD VOLUME Blood volume increases by approximately 1,500 mL, or up to 50% above

nonpregnant levels, by the 32nd week of gestation, and remains more or less constant thereafter (Foo et al., 2015). The increase is made up of 1,000 mL plasma plus 450 mL red blood cells. It begins at weeks 10 to 12, peaks at weeks 32 to 34, and decreases slightly by week 40.

Take Note! The rise in blood volume correlates directly with fetal weight, supporting the concept of the placenta as an arteriovenous shunt in the maternal vascular compartment. This increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues, to supply blood flow to perfuse the enlarging uterus, and to provide a reserve to compensate for blood loss at birth and during postpartum. The maternal blood volume expansion occurs at a larger proportion than the increase in red blood cell mass, which results in physiologic anemia and hemodilution. Criteria of physiologic anemia include hemoglobin 10 g or less; red blood cells 3.5 million/mm3 and normal morphology with central pallor (Sabina et al., 2015). This increase is also necessary to meet the increased metabolic needs of the mother and to meet the need for increased perfusion of other organs, especially the woman’s kidneys, because she is excreting waste products for herself and the fetus. CARDIAC OUTPUT AND HEART RATE Cardiac output, the product of stroke volume and heart rate, is a measure of the functional capacity of the heart. It increases from 30% to 50% over the nonpregnant rate by the 32nd week of pregnancy and declines to about a 20% increase at 40 weeks’ gestation. The increase in cardiac output is associated with an increase in venous return and greater right ventricular output, especially in the left lateral position (Bope & Kellerman, 2015). Heart rate increases by 10 to 15 bpm between 14 and 20 weeks of gestation, and this persists to term. There is slight hypertrophy or enlargement of the heart during pregnancy. This is probably to accommodate the increase in blood volume and cardiac output. The heart works harder and pumps more blood to supply the oxygen needs of the fetus as well as those of the mother. Both heart rate and venous return are increased in pregnancy, contributing to the increase in cardiac output seen

throughout gestation. A woman with pre-existing heart disease may become symptomatic and begin to decompensate during the time the blood volume peaks. Close monitoring is warranted during 28 to 35 weeks’ gestation. BLOOD PRESSURE Blood pressure, especially the diastolic pressure, declines slightly during pregnancy as a result of peripheral vasodilation caused by progesterone. It usually reaches a low point at midpregnancy and thereafter increases to prepregnancy levels until term. During the first trimester, blood pressure typically remains at the prepregnancy level. During the second trimester, the blood pressure decreases 5 to 10 mm Hg and thereafter returns to first-trimester levels (Gaillard & Jaddoe, 2015). Any significant rise in blood pressure during pregnancy should be investigated to rule out gestational hypertension. Gestational hypertension is a clinical diagnosis defined by the new onset of hypertension (systolic of 140 mm Hg or higher and/or diastolic of 90 mm Hg or higher) after 20 weeks gestation. BLOOD COMPONENTS The number of red blood cells also increases throughout pregnancy to a level which is 25% to 33% higher than nonpregnant values, depending on the amount of iron available. This increase is necessary to transport the additional oxygen required during pregnancy. Although there is an increase in red blood cells, there is a greater increase in the plasma volume as a result of hormonal factors and sodium and water retention. Because the plasma increase exceeds the increase of red blood cell production, normal hemoglobin and hematocrit values decrease. This state of hemodilution is referred to as physiologic anemia of pregnancy. Changes in red blood cell volume are due to increased circulating erythropoietin and accelerated red blood cell production. The rise in erythropoietin in the last two trimesters is stimulated by progesterone, prolactin, and human placental lactogen (Jones & Lopez, 2014). Iron requirements during pregnancy increase because of the demands of the growing fetus and the increase in maternal blood volume. The fetal tissues prevail over the mother’s tissues with respect to use of iron stores. With the accelerated production of red blood cells, iron is necessary for hemoglobin formation, the oxygen-carrying component of red blood cells.

Take Note! Many women enter pregnancy with insufficient iron stores and thus need supplementation to meet the extra demands of pregnancy. Both fibrin and plasma fibrinogen levels increase along with various bloodclotting factors. These factors make pregnancy a hypercoagulable state. These changes, coupled with venous stasis secondary to venous pooling, which occurs during late pregnancy after long periods of standing in the upright position with the pressure exerted by the uterus on the large pelvic veins, contribute to slowed venous return, pooling, and dependent edema. These factors also increase the woman’s risk for venous thrombosis (DeLoughery, 2015).

Respiratory System The growing uterus and the increased production of the hormone progesterone cause the lungs to function differently during pregnancy. Oxygen consumption reflects the uptick of maternal metabolism by increasing between 20% and 30% by the time full term is reached. During pregnancy, the amount of space available to house the lungs decreases as the uterus puts pressure on the diaphragm and causes it to shift upward by 4 cm above its usual position. The growing uterus does change the size and shape of the thoracic cavity, but diaphragmatic excursion increases, chest circumference increases by 2 to 3 in, and the transverse diameter increases by an inch, allowing a larger tidal volume, as evidenced by deeper breathing (Tidal volume, or the volume of air inhaled, increases by 30% to 40% (from 500 to 700 mL) as the pregnancy progresses. This increases results in maternal hyperventilation and hypocapnia. As a result of these changes, the woman’s breathing becomes more diaphragmatic than abdominal. Concomitant with the increase in tidal volume is a 30% to 40% increase in maternal oxygen consumption due to the increased oxygen requirements of the developing fetus, placenta, and maternal organs. Anatomic and physiologic changes of pregnancy predispose the mother to increased morbidity and mortality and increase the risks of a less than optimal outcome for the fetus. The frequency and significance of acute and chronic respiratory conditions in pregnant women have increased in recent years. Because of these various changes, pregnant women with asthma, pneumonia, or other respiratory pathology are more susceptible to early decompensation

(Mehta et al., 2015). A pregnant woman breathes faster and more deeply because she and the fetus need more oxygen. Oxygen consumption increases during pregnancy even as airway resistance and lung compliance remain unchanged. Changes in the structures of the respiratory system take place to prepare the body for the enlarging uterus and increased lung volume (Alexander et al., 2014). As muscles and cartilage in the thoracic region relax, the chest broadens, with a conversion from abdominal breathing to thoracic breathing. This leads to a 50% increase in air volume per minute. All of these structural alterations are temporary and revert back to their prepregnant state at the end of the pregnancy. Increased vascularity of the respiratory tract is influenced by increased estrogen levels, leading to congestion. Rising levels of sex hormones and heightened sensitivity to allergens may influence the nasal mucosa, precipitating epistaxis (nosebleed) and rhinitis. This congestion gives rise to nasal and sinus stuffiness and changes in the tone and quality of the woman’s voice (Jordan et al., 2014).

Renal/Urinary System Hormonal changes during pregnancy allow for increased blood flow to the kidneys. The renal system must handle the effects of increased maternal intravascular and extracellular volume and metabolic waste products as well as excretion of fetal wastes. The predominant structural change in the renal system during pregnancy is dilation of the renal pelvis and uterus. Changes in renal structure occur as a result of the hormonal influences of estrogen and progesterone, pressure from an enlarging uterus, and an increase in maternal blood volume. Like the heart, the kidneys work harder throughout the pregnancy. Changes in kidney function occur to accommodate a heavier workload while maintaining a stable electrolyte balance and blood pressure. As more blood flows to the kidneys, the glomerular filtration rate (GFR) increases, leading to an increase in urine flow and volume, substances delivered to the kidneys, and filtration and excretion of urea, uric acid, creatinine, water and solutes (Cox & Reid, 2015). Anatomically, the kidneys enlarge during pregnancy. Each kidney increases in length by approximately 1 to 1.5 cm and weight as a result of hormonal effects that cause increased tone and decreased motility of the smooth muscle. The renal pelvis becomes dilated. The ureters (especially the right ureter) elongate, widen,

and become more curved above the pelvic rim as early as the 10th gestational week (Thadhani & Maynard, 2015). Progesterone is thought to cause both of these changes because of its relaxing influence on smooth muscle. Blood flow to the kidneys increases by 50% to 80% as a result of the increase in cardiac output and relaxin which causes a decrease in both efferent and afferent resistance. This in turn leads to an increase in the GFR by as much as 40% to 60% starting during the second trimester, resulting in hyperfiltration. This elevation continues until birth. This change has important clinical implications for medication use because renally excreted drugs may require higher doses and more frequent administration for therapeutic blood levels during pregnancy (Larson, 2015). The activity of the kidneys normally increases when a person lies down and decreases on standing. This difference is amplified during pregnancy, which is one reason a pregnant woman feels the need to urinate frequently while trying to sleep. Late in the pregnancy, the increase in kidney activity is even greater when the woman lies on her side rather than her back. Lying on either side relieves the pressure that the enlarged uterus puts on the vena cava carrying blood from the legs. Subsequently, venous return to the heart increases, leading to increased cardiac output. Increased cardiac output results in increased renal perfusion and glomerular filtration. As a rule, all the physiologic changes maximize by the end of the second trimester and then start to return to the prepregnant level. However, changes in the anatomy take up to 3 months postpartum to subside (King et al., 2015).

Musculoskeletal System Changes in the musculoskeletal system are progressive, resulting from the influence of hormones, fetal growth, and maternal weight gain. Pregnancy is characterized by changes in posture and gait. By the 10th to 12th week of pregnancy, the ligaments that hold the sacroiliac joints and the pubis symphysis in place begin to soften and stretch, and the articulations between the joints widen and become more movable (Bope & Kellerman, 2015). The relaxation of the joints peaks by the beginning of the third trimester. The purpose of these changes is to increase the size of the pelvic cavity and to make delivery easier.

FIGURE 11.3 Postural changes during (A) the first trimester and (B) the third trimester.

The postural changes of pregnancy—an increased swayback and an upper spine extension to compensate for the enlarging abdomen—coupled with the loosening of the sacroiliac joints may result in lower back pain. The woman’s center of gravity shifts forward, requiring a realignment of the spinal curvatures. Factors thought to contribute to these postural changes include the alteration to the center of gravity that come with pregnancy, the influence of the pregnancyrelated hormone relaxin on the pelvic joints, and the increasing weight and position of the growing fetus. An increase in the normal lumbosacral curve (lordosis) occurs and a compensatory curvature in the cervicodorsal area develops to assist her in maintaining her balance (Fig. 11.3). In addition, relaxation and increased mobility of joints occur because of the hormones progesterone and relaxin, which lead to the characteristic “waddle” gait that pregnant women demonstrate toward term. Increased weight gain can add to this discomfort by accentuating the lumbar and dorsal curves (Kouhkan et al., 2015).

Integumentary System There are a variety of skin changes that are associated with pregnancy. Increased activity of the maternal adrenal and pituitary glands, along with a contribution

for the developing fetal endocrine glands, increasing cortisone levels, accelerated metabolism, and enhanced production of progesterone and estrogenic hormones are responsible for most skin changes in pregnancy (Tyler, 2015). Up to 90% of pregnant women will show signs of hyperpigmentation during pregnancy, and it is typically generalized and mild. The skin of pregnant women undergoes hyperpigmentation primarily as a result of estrogen, progesterone, and melanocyte-stimulating hormone levels. These changes are mainly seen on the nipples, areola, umbilicus, perineum, and axilla. Although many integumentary changes disappear after giving birth, some only fade. Many pregnant women express concern about stretch marks, skin color changes, and hair loss. Unfortunately, little is known about how to avoid these changes. Complexion changes are not unusual. The increased pigmentation that occurs on the breasts and genitalia also develops on the face to form the “mask of pregnancy,” which is also called facial melisma. It occurs in up to 70% of pregnant women. There is a genetic predisposition toward melasma, which is exacerbated by the sun, and it tends to recur in subsequent pregnancies. This blotchy, brownish pigment covers the forehead and cheeks in dark-haired women. Most facial pigmentation fades as the hormones subside at the end of the pregnancy, but some may linger. The skin in the middle of the abdomen may develop a pigmented line called linea nigra, which extends from the umbilicus to the pubic area (Fig. 11.4). Striae gravidarum, or stretch marks, are irregular reddish streaks that appear on the abdomen, breasts, and buttocks in up to 90% of pregnant women. Striae are most prominent by 6 to 7 months. They result from genetics, reduced connective tissue strength resulting from the elevated adrenal steroid levels, and stretching of the structures secondary to growth (Tyler, 2015). They are more common in younger women, women with larger infants, and women with higher body mass indices. Nonwhites and women with a history of breast or thigh striae or a family history of striae gravidarum also are at higher risk. Several creams and lotions such as cocoa butter and olive oil have been touted as being able to prevent striae gravidarum, but research currently does not validate these claims. A study done by Tretti Clementoni and Lavagno (2015) did find that laser treatments did improve pigmentation, volume, and textural appearance of striae gravidarum in more than 50% of the women enrolled in the study.

FIGURE 11.4 Linea nigra.

VASCULAR-RELATED SKIN CHANGES Vascular changes during pregnancy manifested in the integumentary system include varicosities of the legs, vulva, and perineum. Varicose veins commonly are the result of distention, instability, and poor circulation secondary to prolonged standing or sitting and the heavy gravid uterus placing pressure on the pelvic veins, preventing complete venous return. Interventions to reduce the risk of developing varicosities include: • Elevating both legs when sitting or lying down • Avoiding prolonged standing or sitting; changing position frequently • Resting in the left lateral position • Walking daily for exercise • Avoiding tight clothing or knee-high hosiery • Wearing support hose if varicosities are a pre-existing condition to pregnancy Another skin manifestation, believed to be secondary to vascular changes and high estrogen levels, is the appearance of small blood vessels called vascular spiders. They may appear on the neck, thorax, face, and arms. They are

especially obvious in white women and typically disappear after childbirth. Palmar erythema is a well-delineated pinkish area on the palmar surface of the hands. This integumentary change is also related to elevated estrogen levels (Trupin, 2015). HAIR AND NAILS Some women also notice a decline in hair growth during pregnancy. The hair follicles normally undergo a growing and resting phase. The resting phase is followed by a loss of hair; the hairs are then replaced by new ones. During pregnancy, fewer hair follicles go into the resting phase. After delivery, the body catches up with subsequent hair loss for several months. Nails typically grow faster during pregnancy. Pregnant women may experience increased brittleness, distal separation of the nail bed, whitish discoloration, and transverse grooves on the nails, but most of these conditions resolve in the postpartum period (King et al., 2015).

Endocrine System The endocrine system undergoes many changes during pregnancy because hormonal changes are essential in meeting the needs of the growing fetus. Hormonal changes play a major role in controlling the supplies of maternal glucose, amino acids, and lipids to the fetus. Although estrogen and progesterone are the main hormones involved in pregnancy changes, other endocrine glands and hormones also change during pregnancy. THYROID GLAND The thyroid gland enlarges slightly and becomes more active during pregnancy as a result of increased vascularity and hyperplasia. Increased gland activity results in an increase in thyroid hormone secretion starting during the first trimester; levels taper off within a few weeks after birth and return to normal limits. Maternal thyroid hormone is transferred to the fetus beginning soon after conception and is critical for fetal brain development, neurogenesis, and organizational processes prior to 20 weeks when fetal thyroid production is low. However, even after the fetal thyroid is producing increasing amounts of hormone, much of the thyroxin (T4) needed for development continues to be provided by the mother. Low maternal thyroid levels with thyroid insufficiency, hypothyroidism, or low or inadequate iodine intake may compromise fetal

neurologic development (Pearce, 2015). With an increase in the secretion of thyroid hormones, the basal metabolic rate (the amount of oxygen consumed by the body over a unit of time in milliliters per minute) progressively increases by 25%, along with heart rate and cardiac output (Medici et al., 2015). PITUITARY GLAND During pregnancy, major endocrine and metabolic alterations occur due to the physiologic hormonal secretion from the placenta. The pituitary gland adapts to these changes and all secretory axes are affected. During pregnancy, the pituitary gland enlarges; it returns to normal size after birth. The anterior lobe of the pituitary is glandular tissue and produces multiple hormones. The release of these hormones is regulated by releasing and inhibiting hormones produced by the hypothalamus. Some of these anterior pituitary hormones induce other glands to secrete their hormones. The increase in blood levels of the hormones produced by the final target glands (e.g., the ovary or thyroid) inhibits the release of anterior pituitary hormones. Changes in levels of pituitary hormones are discussed in the following paragraphs. FSH and LH secretion are inhibited during pregnancy, probably as a result of hCG produced by the placenta and corpus luteum, and the increased secretion of prolactin by the anterior pituitary gland. Levels remain decreased until after delivery. Thyroid-stimulating hormone (TSH) is reduced during the first trimester but usually returns to normal for the remainder of the pregnancy. Decreased TSH is thought to be one of the factors, along with elevated hCG levels, associated with morning sickness, nausea, and vomiting during the first trimester. Growth hormone (GH) is an anabolic hormone that promotes protein synthesis. It stimulates most body cells to grow in size and divide, facilitating the use of fats for fuel and conserving glucose. During pregnancy, there is a decrease in the number of GH-producing cells and a corresponding decrease in GH blood levels. The action of human placental lactogen (hPL) is thought to decrease the need for and use of GH. During pregnancy, prolactin is secreted in pulses and increases 10-fold to promote breast development and the lactation process. High levels of progesterone secreted by the placenta inhibit the direct influence of prolactin on the breast during pregnancy, thus suppressing lactation. At birth, as soon as the placenta is expelled and there is a drop in progesterone, lactogenesis can begin. Prolactin, released from the anterior pituitary gland in response to suckling by the newborn is the major hormonal signal responsible

for stimulation in the breasts (Crowley, 2015). Melanocyte-stimulating hormone (MSH), another anterior pituitary hormone, increases during pregnancy. For many years, its increase was thought to be responsible for many of the skin changes of pregnancy, particularly changes in skin pigmentation (e.g., darkening of the areola, melasma, and linea nigra). However, currently it is thought that the skin changes are due to estrogen (and possibly progesterone) as well as the increase in MSH. The two hormones oxytocin and antidiuretic hormone (ADH) released by the posterior pituitary are actually synthesized in the hypothalamus. They migrate along nerve fibers to the posterior pituitary and are stored until stimulated to be released into the general circulation. Oxytocin is released by the posterior pituitary gland, and its production gradually increases as the fetus matures (Kim, Bennett, & Terzidou, 2015). Oxytocin is responsible for uterine contractions, both before and after delivery. The muscle layers of the uterus (myometrium) become more sensitive to oxytocin near term. Toward the end of a term pregnancy, levels of progesterone decline and contractions that were previously suppressed by progesterone begin to occur more frequently and with stronger intensity. This change in the hormonal levels is believed to be one of the initiators of labor. Oxytocin is responsible for stimulating the uterine contractions that bring about delivery. Contractions lead to cervical thinning and dilation. They also exert pressure, helping the fetus to descend in the pelvis for eventual delivery. After delivery, oxytocin secretion continues, causing the myometrium to contract and helping to constrict the uterine blood vessels, decreasing the amount of vaginal bleeding after delivery. Oxytocin is also responsible for milk ejection during breast-feeding. Stimulation of the breasts through sucking or touching stimulates the secretion of oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the myoepithelial cells in the lactating mammary gland. Women experience cramping pain and discomfort following childbirth as the uterus contracts and returns to its prepregnant size. These after pains are caused by involuntary contractions and usually last for a few days after childbirth. They are more evident in women who have previously had a baby. Breastfeeding signals the release of oxytocin, which stimulates the uterus to contract and increases the severity of after birth pains. Vasopressin, also known as ADH functions to inhibit or prevent the formation of urine via vasoconstriction, which results in increased blood pressure. Vasopressin also exhibits an antidiuretic effect and plays an important role in the

regulation of water balance (Cheng, 2015). PANCREAS The pancreas is an exocrine organ, supplying digestive enzymes and buffers, and an endocrine organ. The endocrine pancreas consists of the islets of Langerhans, which are groups of cells scattered throughout, each containing four cell types. One of the cell types is the beta cell, which produces insulin. Insulin lowers blood glucose by increasing the rate of glucose uptake and utilization by most body cells. The growing fetus needs significant amounts of glucose, amino acids, and lipids. Even during early pregnancy the fetus makes demands on the maternal glucose stores. Ideally, hormonal changes of pregnancy help meet fetal needs without putting the mother’s metabolism out of balance. A woman’s insulin secretion works on a supply versus demand mode. As the demand to meet the needs of pregnancy increases, more insulin is secreted. Maternal insulin does not cross the placenta, so the fetus must produce his or her own supply to maintain glucose control. (Box 11.2 gives information about pregnancy, glucose, and insulin.) Maternal glucose metabolism during pregnancy differs from the nongravid state to allow the mother to meet her own and the growing fetus’s energy needs. During the first half of pregnancy, much of the maternal glucose is diverted to the growing fetus, and thus the mother’s glucose levels are low. Human placental lactogen and other hormonal antagonists increase during the second half of pregnancy. Therefore, the mother must produce more insulin to overcome the resistance by these hormones. Insulin resistance (the inability of insulin to increase glucose uptake and utilization) in pregnancy is consequent to the physiologic adaptation necessary to provide glucose to the growing fetus. Disturbance in the maternal metabolism can induce structural and functional adaptations during fetal development (Nas, Breyer, & Tuu, 2015).

BOX 11.2 PREGNANCY, INSULIN, AND GLUCOSE • During early pregnancy, maternal glucose levels decrease because of the heavy fetal demand for glucose. The fetus is also drawing amino acids and lipids from the mother, decreasing the mother’s ability to synthesize glucose. Maternal glucose is diverted across the placenta to assist the growing embryo/fetus during early pregnancy, and thus levels decline in the mother. As a result, maternal glucose concentrations decline to a level that would be considered “hypoglycemic” in a nonpregnant woman. • During early pregnancy there is also a decrease in maternal insulin production and insulin levels. The pancreas is responsible for the production of insulin, which facilitates entry of glucose into cells. Although glucose and other nutrients easily cross the placenta to the fetus, insulin does not. Therefore, the fetus must produce its own insulin to facilitate the entry of glucose into its own cells. • After the first trimester, hPL from the placenta and steroids (cortisol) from the adrenal cortex act against insulin. hPL acts as an antagonist against maternal insulin, and thus more insulin must be secreted to counteract the increasing levels of hPL and cortisol during the last half of pregnancy. • Prolactin, estrogen, and progesterone are also thought to oppose insulin. As a result, glucose is less likely to enter the mother’s cells and is more likely to cross over the placenta to the fetus. Adapted from Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., et al. (2014). William’s Obstetrics (24th ed.). New York, NY: McGraw Hill Education.

If the mother has normal beta cells of the islets of Langerhans, there is usually no problem meeting the demands for extra insulin. However, if the woman has inadequate numbers of beta cells, she may be unable to produce enough insulin and will develop glucose intolerance during pregnancy. If the woman has glucose intolerance, she is not able to meet the increasing demands and her blood glucose level increases.

ADRENAL GLANDS Pregnancy does not cause much change in the size of the adrenal glands themselves, but there are changes in some secretions and activity. One of the key changes is the marked increase in cortisol secretion, which regulates carbohydrate and protein metabolism and is helpful in times of stress. Although pregnancy is considered a normal condition, it is a time of stress for a woman’s body. The rate of secretion of cortisol by maternal adrenals is not increased in pregnancy, but the rate of clearance is decreased. Cortisol increases in response to increased estrogen levels throughout pregnancy and returns to normal levels within 6 weeks postpartum (Banerjee & Williamson, 2015). During the stress of pregnancy, cortisol: • Helps keep up the level of glucose in the plasma by breaking down noncarbohydrate sources, such as amino and fatty acids, to make glycogen. Glycogen, stored in the liver, is easily broken down to glucose when needed so that glucose is available in times of stress. • Breaks down proteins to repair tissues and manufacture enzymes. • Has anti-insulin, anti-inflammatory, and anti-allergic actions. • Is needed to make the precursors of adrenaline, which the adrenal medulla produces and secretes (Jones & Lopez, 2014). The amount of aldosterone, also secreted by the adrenal glands, is increased during pregnancy. It normally regulates absorption of sodium from the distal tubules of the kidney. During pregnancy, progesterone allows salt to be wasted (or lost) in the urine. Aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. Hormonal changes during pregnancy, among them increased progesterone and aldosterone production, lead to the required plasma volume expansion of the maternal body as an accommodation mechanism for fetus growth. Aldosterone is produced in increased amounts by the adrenal glands as early as 15 weeks of pregnancy (Rossier, Baker, & Studer, 2015). PROSTAGLANDIN SECRETION DURING PREGNANCY Prostaglandins are not protein or steroid hormones; they are chemical mediators, or local hormones. Although hormones circulate in the blood to influence distant tissues, prostaglandins act locally on adjacent cells. The fetal membranes of the amniotic sac—the amnion and chorion—are both believed to be involved in the

production of prostaglandins. Various maternal and fetal tissues, as well as the amniotic fluid itself, are considered to be sources of prostaglandins, but details about their composition and sources are limited. It is widely believed that prostaglandins play a part in softening the cervix and initiating and/or maintaining labor, but the exact mechanism is unclear. What is theorized is that when progesterone levels drop at term, an increased production of prostaglandins occurs, which facilitates uterine contractions and increases myometrial sensitivity to oxytocin that is needed for the labor process (King et al., 2015). Along with oxytocin, the influence of prostaglandins on the uterine myometrium predominates to promote uterine contractile activity. PLACENTAL SECRETION The placenta is an organ that serves to prevent the direct exchange between the blood of the fetus and the blood of the mother. The placenta is not only a transfer organ but a factory as well. It is capable of synthesizing enzymes and proteins, and manufactures fats and carbohydrates that serve as a source of stored energy. The placenta also functions as an endocrine gland, manufacturing and secreting hormones. The placenta has a feature possessed by no other endocrine organ— the ability to form protein and steroid hormones. Very early during pregnancy, the placenta begins to produce the following hormones: • hCG • hPL • Relaxin • Progesterone • Estrogen Table 11.3 summarizes the role of these hormones.

Immune System The immune system is made up of organs and specialized cells whose primary purpose is to defend the body from foreign substances (antigens) that may cause tissue injury or disease. The mechanisms of innate and adaptive immunity work cooperatively to prevent, control, and eradicate foreign antigens in the body. A general enhancement of innate immunity (inflammatory response and phagocytosis) and suppression of adaptive immunity (protective response to a

specific foreign antigen) take place during pregnancy. These immunologic alterations help prevent the mother’s immune system from rejecting the fetus (foreign body), increase her risk of developing certain infections such as urinary tract infections, and influence the course of chronic disorders such as autoimmune diseases. Some chronic conditions worsen (diabetes) while others seem to stabilize (asthma) during pregnancy, but this is individualized and not predictable. In general, immune function in pregnant women is similar to immune function in nonpregnant women. Table 11.4 summarizes the general body systems’ adaptations to pregnancy. Marva returns for her first prenatal appointment and tells the nurse that her whole body is “out of sorts.” She is overwhelmed and feels poorly. Outline the bodily changes Marva can expect each trimester to help her understand the adaptations taking place. What guidance can the nurse give Marva to help her understand the changes of pregnancy?

CHANGING NUTRITIONAL NEEDS OF PREGNANCY Maternal body weight and diet quality, even prepregnancy, can affect the uterine environment, birth weight, and the infant’s subsequent health into adulthood. Healthy eating during pregnancy enables optimal gestational weight gain and reduces complications, both of which are associated with positive birth outcomes. During pregnancy, maternal nutritional needs change to meet the demands of the pregnancy. Healthy eating can help ensure that adequate nutrients are available for both mother and fetus. TABLE 11.3 PLACENTAL HORMONES

Nutritional intake during pregnancy has a direct effect on fetal well-being and birth outcome. Inadequate nutritional intake, for example, is associated with preterm birth, low birth weight, and congenital anomalies. Excessive nutritional intake is connected with fetal macrosomia (>4,000 g), leading to a difficult birth, neonatal hypoglycemia, and continued obesity in the mother and the potential for childhood obesity and the components of metabolic syndrome (Ojha et al., 2015). Since the requirements for so many nutrients increase during pregnancy, pregnant women should take a vitamin and mineral supplement daily. Prenatal vitamins are prescribed routinely as a safeguard against a less-than-optimal diet. In particular, iron and folic acid need to be supplemented because their increased

requirements during pregnancy are usually too great to be met through diet alone. With the exception of folic acid, there is little scientific evidence to support giving vitamin supplements to healthy pregnant women, but it seems to be the standard of care today. Prenatal vitamins are prescribed in the United States almost universally (Jordan et al., 2014). Iron and folic acid are needed to form new blood cells for the expanded maternal blood volume and to prevent anemia. Iron is essential for fetal growth and brain development and in the prevention of maternal anemia. An increase in folic acid is essential before pregnancy and in the early weeks of pregnancy to prevent neural tube defects in the fetus. For most pregnant women, supplements of 27 mg of ferrous iron and 400 to 800 mcg of folic acid per day are recommended by the dietary reference intakes (DRIs) (American College of OB/GYN [ACOG], 2015a); (Hankey, 2015); and (U.S. Preventive Services Task Force [USPSTF], 2015). Women with a previous history of a fetus with a neural tube defect are often prescribed a higher dose of folic acid. TABLE 11.4 SUMMARY OF GENERAL BODY SYSTEM ADAPTATIONS

There is an abundance of conflicting advice about nutrition during pregnancy and what is good or bad to eat. Overall, the following guidelines are helpful: • Increase consumption of fruits and vegetables. • Replace saturated fats with unsaturated ones. • Make half the plate fruits and vegetables. • Choose whole grains in place of refined grains. • Choose foods with a lot of fiber to prevent constipation. • Avoid hydrogenated or partially hydrogenated fats. • Do not consume any alcoholic beverages. • Use reduced-fat spreads and dairy products instead of full-fat ones. • Eat at least two servings of fish weekly, with one of them being an oily fish. • Consume at least 2 quarts of water daily (USDA, 2015). In the months before conception, food choices are key. The foods and vitamins consumed can ensure that the woman and her fetus will have the nutrients that are essential for the very start of pregnancy. While most women recognize the importance of healthy eating during

pregnancy, some find it challenging to achieve. Many women say they have little time and energy to devote to meal planning and preparation. Another barrier to healthy eating is conflicting messages from various sources, resulting in a lack of clear, reliable, and relevant information. Moreover, many women are eating less in an effort to control their weight, putting them at greater risk of inadequate nutrient intake.

Nutritional Requirements During Pregnancy Pregnancy is one of the most nutritionally demanding periods of a woman’s life. Gestation involves rapid cell division and organ development, and an adequate supply of nutrients is essential to support this tremendous fetal growth. Optimal maternal health via good nutritional practices during pregnancy reduces the risk of suboptimal fetal development. Most women are usually motivated to eat properly during pregnancy for the sake of the fetus. The Food and Nutrition Board of the National Research Council has made recommendations for nutrient intakes for people living in the United States. The DRIs are more comprehensive than previous nutrient guidelines issued by the Board. They have replaced previous recommendations because they are not limited to preventing deficiency diseases. Rather, the DRIs incorporate current concepts about the role of nutrients and food components in reducing the risk of chronic disease, developmental disorders, and other related problems. The DRIs can be used to plan and assess diets for healthy people (Kruger & Butte, 2015). These dietary recommendations also include information for women who are pregnant or lactating, because growing fetal and maternal tissues require increased quantities of essential dietary components. For example, the current DRIs suggest an increase in the pregnant woman’s intake of protein from 60 to 80 g/day, iron from 18 to 27 g/day, and folic acid from 400 to 800 mcg/day, along with an increase of 300 calories/day over the recommended intake of 1,800 to 2,200 calories/day for nonpregnant women (Storck, 2015; Walsh & McAuliffe, 2015) (Table 11.5).

Gluten-free Diet During Pregnancy In recent years, gluten-free foods have become popular, fueling a growing market for the Food Industry. Pregnant women may be missing out on important nutrients if they adopt gluten-free diets as many are also joining the everexpanding “G-free” bandwagon. Many people feel that these products are healthier than their conventional counterparts. But is it really a health-promotion diet or just another trend during pregnancy? Gluten may have gotten its bad rap because it is frequently found in many processed and unhealthy foods. Several gluten-free foods contain more fat, including saturated, and sodium, but fewer minerals and vitamins than their equivalents with gluten (Pellegrini & Agostoni, 2015). Skipping processed foods altogether and focusing on fruits, vegetables, lean protein, and whole grains would provide a well-balanced healthy diet. Eating a gluten-free diet can make it hard to get the recommended amount of folate, vitamin B, iron, calcium, fiber, and grain-servings that all pregnant women need. That is why, unless there is medical reason in which gluten must be eliminated from the diet due to celiac disease or a gluten allergy, there is no scientific reason to cut out wholesome, nutrient-dense grains from the diet (Neifeld, 2015).

USDA and MyPlate For a pregnant woman to meet recommended DRIs, she should eat according to the U.S. Department of Agriculture (USDA) Food Guide MyPlate (Fig. 11.5). The USDA Food Guide MyPlate replaced the Food Guide Pyramid in 2011 as the government’s primary food group symbol. MyPlate is an easy-to-understand visual cue to help consumers adopt healthy eating habits by encouraging them to build a healthy plate, consistent with the Dietary Guidelines for Americans, 2015 (USDA & USDHHS, 2015), which are the basis for federal nutrition policy (USDA and U.S. Department of Health and Human Services [USDHHS], 2015). This new tool will serve as a basis for dietary instruction and it can be tailored to meet each woman’s individual needs. TABLE 11.5 DIETARY RECOMMENDATIONS FOR THE PREGNANT AND LACTATING WOMAN

FIGURE 11.5 Food Guide MyPlate for pregnancy.

MyPlate provides guidance to help implement the dietary guidelines. The USDA has designed an interactive online diet-planning program called the Daily Food Plan for Moms that helps pregnant women personalize their dietary intake throughout their pregnancy. (Refer to for additional information about this food plan.) A summary of the new guidelines is as follows: • Eat a variety of food from all food groups using portion control.

• Increase intake of vitamins, minerals, and dietary fiber. • Lower intake of saturated fats, trans fats, and cholesterol. • Consume adequate synthetic folic acid from supplements or from fortified foods. • Increase intake of fruits, vegetables, and whole grains. • Balance calorie intake with exercise to maintain ideal healthy weight (USDA, 2015). An eating plan that follows MyPlate should provide sufficient nutrients for a healthy pregnancy. Except for iron, folic acid, and calcium, most of the nutrients a woman needs during pregnancy can be obtained by making healthy food choices. However, a vitamin and mineral supplement is generally prescribed.

Take Note! Good food sources of folic acid include dark green vegetables, such as broccoli, romaine lettuce, and spinach; baked beans, black-eyed peas, citrus fruits, peanuts, and liver.

Food Concerns During Pregnancy ARTIFICIAL SWEETENERS Artificial sweeteners or intense sweeteners are sugar substitutes that are used as an alternative to table sugar. They are many times sweeter than natural sugar and contain no calories. Extensive scientific research has demonstrated the safety of the six low-calorie sweeteners currently approved for use in foods in the United States and Europe (stevia, acesulfame-K, aspartame, neotame, saccharin, and sucralose), if taken in acceptable quantities daily. But there is an ongoing debate over whether artificial sweeteners pose a health threat (Qurrat-ul-Ain & Khan, 2015). The safety of artificial sweeteners consumed during pregnancy remains controversial also. Some health care providers advise their pregnant clients to avoid all nonnutritive sweeteners during pregnancy, while others suggest they can be used in moderation (Hankley, 2015). The debate continues on this matter until additional research can be completed.

FISH, SHELLFISH, AND LEVELS OF MERCURY Fish and shellfish are an important part of a healthy diet because they contain high-quality protein, are low in saturated fat, and contain omega-3 fatty acids. However, nearly all fish and shellfish contain traces of mercury and some contain higher levels of mercury that may harm a developing fetus if ingested by pregnant women in large amounts. Human exposure to mercury occurs primarily through the consumption of fish contaminated through atmospheric mercury releases. The U.S. Environmental Protection Agency (EPA) and the United Nations Environment Program have identified coal-fired power plants as the source of 50% to 75% of the atmospheric mercury pollution in the United States and worldwide. Once airborne, rainfall transfers mercury particles into waterways where it is converted to the neurotoxic methylmercury form through a microbial process. Plankton absorbs the methylmercury and as the smaller fish eat the plankton and the larger predatory fish consume the smaller fish, the methylmercury bioaccumulates up the food chain to humans. Mercury exposure in pregnancy has been associated with both pregnancy complications and developmental problems in infants. Apart from the environmental exposure, mercury is likely to arise from predatory fish consumption. It would be prudent to advise all pregnant women to avoid these potential problems and minimize any risk. All fish contain methylmercury regardless of the size or the geographic location of the waters from which the fish is caught, although size and type of fish as well as the geographic location of waters can influence lower or higher amounts of methylmercury. In addition, because methylmercury resides in the tissue of the fish, no method of cleaning or cooking will reduce the amount of mercury in a meal of contaminated fish (Nelson, 2015). With this in mind, the FDA and the EPA are advising women who may become pregnant, pregnant women, and nursing mothers to do the following: • Avoid consumption of fish with moderate-to-high mercury levels (e.g., for 6 to 12 months prior to conception and throughout pregnancy). • Avoid eating shark, swordfish, king mackerel, orange roughy, ahi tuna, and tilefish because they are high in mercury levels. • Eat up to 12 oz (two average meals) weekly of low-mercury-level fish such as shrimp, canned light tuna, salmon, pollock, and catfish. • Check local advisories about the safety of fish caught by family and friends in local lakes, rivers, and coastal areas (FDA, 2015).

LISTERIOSIS AND PREGNANCY Another food issue concern for pregnant women is consumption of food contaminated with the gram-positive bacillus Listeria. Listeria is a type of bacteria found in soil, water, and sometimes on plants. Listeria is commonly found in processed and prepared foods and in raw or unpasteurized milk. Listeriosis is associated with high morbidity and mortality. Though Listeria is all around our environment, most Listeria infections in people result from eating contaminated foods. Listeriosis during pregnancy usually presents as an unremarkable febrile illness in the mother, but can be fatal for the fetus and newborn. Reliable laboratory testing for early diagnosis is lacking. Listeriosis can be passed to an unborn baby through the placenta even if the mother is not showing signs of illness. This can lead to preterm births, miscarriages, stillbirths, and high neonatal mortality rates (Allerberger & Huhulescu, 2015). The Food Safety and Inspection Service and the FDA (2015) provide the following advice for pregnant women: • Do not eat hot dogs, luncheon meats, or deli meats unless they are reheated until steaming hot. • Avoid getting fluid from hot dog packages on other foods, utensils, and food preparation surfaces, and wash hands after handling hot dogs, luncheon meats, and deli meats. • Do not eat soft cheeses such as feta, Brie, Camembert, and blue-veined cheeses. • It is safe to eat hard cheeses, semi-soft cheeses such as mozzarella, pasteurized processed cheese slices and spreads, cream cheese, and cottage cheese. • Do not eat refrigerated pâté or meat spreads. • It is safe to eat canned or shelf-stable pâté and meat spreads. • Do not eat refrigerated smoked seafood unless it is an ingredient in a cooked dish such as a casserole. Examples of refrigerated smoked seafood include salmon, trout, whitefish, cod, tuna, and mackerel and are most often labeled as “nova-style,” “lox,” “kippered,” “smoked,” or “jerky.” These refrigerated smoked fish are found in the refrigerated section or sold at deli counters of grocery stores and delicatessens. • It is safe to eat canned fish such as salmon and tuna or shelf-stable smoked seafood. • Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized

milk. • Use all refrigerated perishable items that are precooked or ready-to-eat as soon as possible. • Use a refrigerator thermometer to make sure that the refrigerator always stays at 40° F (about 5° C) or below. • Do not eat salads made in the store such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad. • Clean your refrigerator regularly.

Maternal Weight Gain The amount of weight that a woman gains during pregnancy is not as important as what she eats. A woman can lose extra weight after a pregnancy, but she can never make up for a poor nutritional status during the pregnancy. Earlier guidelines recommended weight gain that would be optimal for the infant, but new guidelines take into account the well-being of the mother too (Table 11.6). In 2009, the Health and Medicine Division revised the recommendations regarding maternal gestational weight gain. The revisions took into account that presently American women (1) have more multiple pregnancies; (2) are becoming pregnant at an older age; (3) are exceeding the ideal weight gain during pregnancy; and (4) tend to be more overweight and obese when becoming pregnant. The new recommendations are based on the woman’s pregnancy body mass index (BMI) as follows (Box 11.3): TABLE 11.6 NORMAL DISTRIBUTION OF WEIGHT GAIN DURING PREGNANCY

BOX 11.3 BODY MASS INDEX Body mass index (BMI) provides an accurate estimate of total body fat and is considered a good method to assess overweight and obesity in people. BMI is a weight-to-height ratio calculation that can be determined by dividing a woman’s weight in kilograms by her height in meters squared. BMI can also be calculated by weight in pounds divided by the height in inches squared, multiplied by 704.5. The Centers for Disease Control and Prevention (CDC) (2015) categorizes BMI as follows: • Underweight: 18.5) total weight gain range = 28–40 lb • Normal weight (BMI = 18.5–24.0) total weight gain range = 25–35 lb • Overweight (BMI = 25–29) total weight gain range = 15–25 lb • Obese (BMI = 30 or higher) total weight gain range = 11–20 lb (HMD, 2009). • Take your prenatal vitamin/mineral supplementation daily. • Avoid weight-reduction diets during pregnancy. • Do not skip meals; eat three meals with one or two snacks daily. • Limit the intake of sodas and caffeine-rich drinks. • Avoid the use of diuretics during pregnancy.

• Do not restrict the use of salt unless instructed to do so by your health care provider. • Engage in reasonable physical activity daily.

Special Nutritional Considerations Many factors play an important role in shaping a person’s food habits, and these factors must be taken into account if nutritional counseling is to be realistic and appropriate. Nurses need to be aware of these factors to ensure individualized teaching and care.

Cultural Variations and Restrictions Food is important to every cultural group. It is often part of celebrations and rituals. When working with women from various cultures, the nurse needs to adapt American nutritional guidelines to meet their nutritional needs within their cultural framework. Food choices and variations for different cultures might include the following: • Bread, cereal, rice, and pasta group: • Bolillo • Couscous • Flaxseed • Hau juan • Vegetable group: • Agave • Bok choy • Jicama • Okra • Water chestnuts • Protein group: • Bean paste • Blood sausage • Legumes • Shellfish • Fruit group: • Catalpa

• Kumquats • Plantain • Yucca fruit • Zapote • Milk and dairy: • Buffalo milk • Buttermilk • Soybean milk (Academy of Nutrition and Dietetics [AND], 2015a)

EVIDENCE-BASED PRACTICE 11.1 Interventions for Nausea and Vomiting in Early Pregnancy Nausea, retching or dry heaving, and vomiting in early pregnancy are very common and can be very distressing for women. Many treatments are available to women with ’morning sickness’, including drugs and complementary and alternative therapies. Because of concerns that taking medications may adversely affect the development of the fetus, this review aimed to examine if these treatments have been found to be effective and safe.

STUDY The purpose of this study was to assess the effectiveness and safety of all interventions for nausea and vomiting in early pregnancy, up to 20 weeks of gestation. Thirty-seven trials involving 5,049 women met the inclusion criteria. These trials covered many interventions, including acupressure, acustimulation, acupuncture, ginger, chamomile, lemon oil, mint oil, vitamin B6, and several antiemetic drugs. Evidence regarding the effectiveness of P6 acupressure, auricular (ear) acupressure, and acustimulation of the P6 point was limited. Acupuncture (P6 or traditional) showed no significant benefit to women in pregnancy. The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent, though two recent studies support ginger over placebo. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and antiemetic drugs to relieve mild or moderate nausea and vomiting. There was little information on maternal and fetal adverse outcomes and on psychological, social, or economic outcomes. The methodological quality of the included studies was mixed.

Findings This review found a lack of high-quality evidence to back up any advice on which interventions to use. Some of the studies showed a benefit in improving nausea and vomiting symptoms for women, but generally effects were inconsistent and limited. Studies were carried out in a way that meant they were at high risk of bias and, therefore, it was difficult to draw firm conclusions. Most studies had different ways of measuring the symptoms of nausea and vomiting and therefore, could not be looked at these findings together. Few studies reported maternal and fetal adverse outcomes and there was very little information on the effectiveness of treatments for improving women’s quality of life.

Nursing Implications Given the high prevalence of nausea and vomiting in early pregnancy, women and nurses caring for them need clear guidance about effective and safe interventions based on systematically reviewed evidence. Diclegis is the only FDA approved medicine for treatment of morning sickness presently, but causes drowsiness, so women should avoid engaging in activities requiring complete mental alertness, such as driving. There is a lack of high-quality evidence to support any particular intervention at this time. This is not the same as saying that the interventions studied are ineffective, but that there is insufficient strong evidence for any one intervention. Advice provided by nurses to pregnant clients experiencing morning sickness should remain general and individualized, based on the findings of this study. Adapted from Matthews, A., Haas, D. M., O’Mathúna, D. P., Dowswell, T., & Doyle, M. (2014). Interventions for nausea and vomiting in early pregnancy. Cochrane Database of Systematic Reviews, (3), CD007575.

Lactose Intolerance The best source of calcium is milk and dairy products, but for women with lactose intolerance, adaptations are necessary. Women with lactose intolerance lack an enzyme (lactase) needed for the breakdown of lactose into its component simple sugars, glucose, and galactose. Without adequate lactase, lactose passes through the small intestine undigested and causes abdominal discomfort, gas, and diarrhea. Lactose intolerance is especially common among women of African, Asian, and Middle Eastern descent (Szilagyi, 2015). Additional or substitute sources of calcium may be necessary. These may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasses (McIndoo, 2015). In addition, encourage the woman to drink lactose-free dairy products or calcium-enriched orange juice or soy milk (Evidence-Based Practice 11.1).

Vegetarians Vegetarian diets are becoming increasingly prevalent in the United States.

People choose a vegetarian diet for various reasons including environmental, animal rights, philosophical, religious, and health beliefs (Dunlevy, 2015). Vegetarians choose not to eat meat, poultry, and fish. Their diets consist mostly of plant-based foods, such as legumes, vegetables, whole grains, nuts, and seeds. Vegetarians fall into groups defined by the types of foods they eat. Lacto-ovovegetarians omit red meat, fish, and poultry, but eat eggs, milk, and dairy products in addition to plant-based foods. Lacto-vegetarians consume milk and dairy products along with plant-based foods; they omit eggs, meat, fish, and poultry. Vegans eliminate all foods from animals, including milk, eggs, and cheese, and eat only plant-based foods (Foster & Samman, 2015). The concern with any form of vegetarianism, especially during pregnancy, is that the diet may be inadequate in nutrients. Other risks of vegetarian eating patterns during pregnancy may include low gestational weight gain, irondeficiency anemia, compromised protein utilization, and decreased mineral absorption (Piccoli et al., 2015). A diet can become so restrictive that a woman is not gaining weight or is consistently not eating enough from one or more of the food groups. Generally, the more restrictive the diet is, the greater the chance of nutrient deficiencies. Well-balanced vegetarian diets that include dairy products provide adequate caloric and nutrient intake and do not require special supplementation; however, vegan diets do not include any meat, eggs, or dairy products. Pregnant vegetarians must pay special attention to their intake of protein, iron, calcium, and vitamin B12. Suggestions include: • For protein: substitute soy foods, beans, lentils, nuts, grains, and seeds. • For iron: eat a variety of meat alternatives, along with vitamin C-rich foods. • For calcium: substitute soy, calcium-fortified orange juice, and tofu. • For vitamin B12: eat fortified soy foods and a B12 supplement. The Academy of Nutrition and Dietetics (2015b), used an evidence-based review to show that well-planned vegetarian diets are appropriate for individuals during all stages of the life cycle, including pregnancy, lactation, infancy, childhood, and adolescence, and for athletes.

Pica Pica is a term used to describe the intense craving for and eating of non-food

items. Many women experience unusual food cravings during their pregnancy. Having cravings during pregnancy is perfectly normal. Sometimes, however, women crave substances that have no nutritional value and can even be dangerous to themselves and their fetus. Pica is the compulsive ingestion of nonfood substances. Pica is derived from the Latin term for magpie, a bird that is known to consume a variety of nonfood substances. Unlike the bird, however, pregnant women who develop a pica habit typically have one or two specific cravings. The exact cause of pica is not known. Many theories have been advanced to explain it, but none has been proven scientifically. The incidence of pica is difficult to determine, since it is underreported. It is more common in the United States among African American women compared with other ethnicities, but the practice of pica is not limited to any one geographic area, race, creed, or culture. In the United States, pica is also common in women from rural areas and women with a family history of it. Common substances ingested include dirt, clay, and laundry starch. Other pica cravings are burnt matches, stones, charcoal, mothballs, ice, cornstarch, toothpaste, soap, sand, plaster, coffee grounds, paint chips, coffee grounds, baking soda, and cigarette ashes (Jyothi, 2015). The three main substances consumed by women with pica are soil or clay (geophagia), ice (pagophagia), and laundry starch (amylophagia). Nutritional implications include: • Soil: replaces nutritive sources and causes iron-deficiency anemia. • Clay: produces constipation; can contain toxic substances and cause parasitic infection. • Ice: can cause iron-deficiency anemia, tooth fractures, freezer burn injuries. • Laundry starch: replaces iron-rich foods, leads to iron deficiencies, and replaces protein metabolism, thus depriving the fetus of amino acids needed for proper development (American Pregnancy Association, 2015). Clinical manifestations of anemia often precede the identification of pica because the health care provider rarely addresses the behavior and the woman does not usually volunteer such information (King et al., 2015). Secrecy surrounding this habit makes research and diagnosis difficult because some women fail to view their behavior as anything unusual, harmful, or worth reporting. Because of the clinical implications, pica should be discussed with all pregnant women as a preventive measure. The topic can be part of a general

discussion of cravings, and the nurse should stress the harmful effects outlined above. Suspect pica when the woman exhibits anemia although her dietary intake is appropriate. Ask about her usual dietary intake, and include questions about the ingestion of nonfood substances. Consider the potential negative outcomes for the pregnant woman and her fetus, and take appropriate action.

PSYCHOSOCIAL ADAPTATIONS DURING PREGNANCY Pregnancy is a unique time in a woman’s life. It is a time of dramatic alterations in her body and her appearance, as well as a time of change in her social status. All of these changes occur simultaneously. Concurrent with the physiologic changes within her body systems are psychosocial changes within the mother and family members as they face significant role and lifestyle changes.

Maternal Emotional Responses Motherhood, perhaps more than any role in the society, has acquired a special significance for women. Women are taught they should find fulfillment and satisfaction in the role of the “ever-bountiful, ever-giving, self-sacrificing mother.” Pregnancy and transitioning to motherhood are critical experiences in a woman’s life, stirring a whole range of powerful emotions (Einstein, 2015). With such high expectations, many pregnant women experience various emotions throughout their pregnancy. The woman’s approach to these emotions is influenced by her emotional makeup, her sociologic and cultural background, her acceptance or rejection of the pregnancy, whether the pregnancy was planned, if the father is known, and her support network (Alexander et al., 2014). Despite the wide-ranging emotions associated with the pregnancy, many women experience similar responses. These responses commonly include ambivalence, introversion, acceptance, mood swings, and changes in body image.

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 by the news, 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, she may participate less with the outside world, and she may appear passive to her family and friends. This introspective behavior is a normal psychological adaptation to motherhood for most women. Introversion 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, including 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 liability 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.

Becoming a Mother Reva Rubin (1984) identified maternal tasks that a woman must accomplish to incorporate the maternal role into her personality. Accomplishing these tasks helps the expectant mother to develop her self-concept as a mother and to form a mutually gratifying relationship with her infant. These tasks are listed in Box 11.4.

BOX 11.4 BECOMING A MOTHER • 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 Adapted from Rubin, R. (1984). Maternal identity and the maternal experience. New York, NY: Springer.

Pregnancy and Sexuality Sexuality is an important part of health and well-being. Sexual behavior modifies as pregnancy progresses, influenced by biologic, psychological, and social factors. 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. The 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 (Bope & Kellerman, 2015). Potential complications of sex during pregnancy include preterm labor, pelvic inflammatory disease, antepartum hemorrhage in placenta previa, and venous air embolism. Generally, sexual relations are generally considered safe in pregnancy. Abstinence is usually only recommended for women who are at risk for preterm labor or for antepartum hemorrhage because of placenta previa (Boynton, 2015). 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 familyrelated social and emotional needs. One prominent feature of this familycentered 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 fewer visible changes than women, but most of these changes remain unexpressed and unappreciated (Davies, 2015). 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—a reaction termed couvade syndrome that is 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 providers. 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, or attending Lamaze classes.

Pregnancy and Siblings A sibling’s reaction to pregnancy is age dependent. Some children might express excitement and anticipation, whereas others might have negative reactions. A young toddler might regress in toilet training or ask to drink from a bottle again. An older school-aged child may ignore the new addition to the family and engage in outside activities to avoid the new member. The introduction of an infant into the family is often the beginning of sibling rivalry, which results from the child’s fear of change in the security of the relationship with his or her parents (Jordan et al., 2014). Preparation of the siblings for the anticipated birth is imperative and must be designed according to the age and life experiences of the sibling at home. Constant reinforcement of love and caring will help to reduce the older child’s fear of change and worry about being replaced by the new family member.

FIGURE 11.6 Parents preparing sibling for the birth of a new baby.

If possible, parents should include siblings in preparation for the birth of the new baby to help them feel as if they have an important role to play (Fig. 11.6). Parents must also continue to focus on the older sibling after the birth to reduce regressive or aggressive behavior toward the newborn. Pregnancy is an extremely busy time, not only in terms of the bodily changes taking place, but tasks that must be done such as choosing a provider to care for them, preparing for the new family member in a matter of months, and making lifestyle modifications to promote the best possible pregnancy outcome. We will

explore this more in Chapter 12. KEY CONCEPTS Pregnancy is a normal life event that involves considerable physical, psychosocial, emotional, and relationship adjustments. The signs and symptoms of pregnancy have been grouped into those that are subjective (presumptive) and experienced by the woman herself, those that are objective (probable) and observed by the health care provider, and those that are the positive, certain signs. Physiologically, almost every system of a woman’s body changes during pregnancy with startling rapidity to accommodate the needs of the growing fetus. A majority of the changes are influenced by hormonal changes. The placenta is a unique kind of endocrine gland; it has a feature possessed by no other endocrine organ—the ability to form protein and steroid hormones. Occurring in conjunction with the physiologic changes in the woman’s body systems are psychosocial changes occurring within the mother and family members as they face significant role and lifestyle changes. Commonly experienced emotional responses to pregnancy in the woman include ambivalence, introversion, acceptance, mood swings, and changes in body image. Reactions of expectant partners to pregnancy and to the physical and psychological changes in the woman vary greatly. A sibling’s reaction to pregnancy is age dependent. The introduction of a new infant to the family is often the beginning of sibling rivalry, which results from the established child’s fear of change in security of their relationships with their parents. Therefore, preparation of the siblings for the anticipated birth is imperative.

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CHAPTER WORKSHEET MULTIPLE-CHOICE QUESTIONS 1. What factors would change during a pregnancy if the hormone progesterone were reduced or withdrawn? a. The woman’s gums would become red and swollen and would bleed easily. b. The uterus would contract more and peristalsis would increase. c. Morning sickness would increase and would be prolonged. d. The secretion of prolactin by the pituitary gland would be inhibited. 2. Which of the following is a presumptive sign or symptom of pregnancy?

a. Restlessness b. Elevated mood c. Urinary frequency d. Low backache 3. When obtaining a blood test for pregnancy, which hormone would the nurse expect the test to measure? a. Human chorionic gonadotropin (hCG) b. Human placental lactogen (hPL) c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH) 4. During pregnancy, which of the following should the expectant mother reduce or avoid? a. Raw meat or uncooked shellfish b. Fresh, washed fruits and vegetables c. Whole grains and cereals d. Protein and iron from meat sources 5. A feeling expressed by most women upon learning they are pregnant is: a. Acceptance b. Depression c. Jealousy d. Ambivalence 6. Reva Rubin identified four major tasks that the pregnant woman undertakes to form a mutually gratifying relationship with her infant. What is “binding in?” a. Ensuring safe passage through pregnancy, labor, and birth. b. Seeking acceptance of this infant by others. c. Seeking acceptance of self as mother to the infant. d. Learning to give of oneself on behalf of the infant. 7. A pregnant client close to term comes in the clinic for an exam. The woman

complains about experiencing shortness of breath. The nurse knows that this complaint can be explained as the: a. Fetus needs more oxygen now that his/her size is larger. b. Fundus of the uterus is high and pushing the diaphragm upwards. c. Woman is experiencing an allergic reaction because of high histamine levels. d. Oxygen partial pressure concentration is lower in the third trimester. 8. Which of the following fish should be limited in a pregnant woman’s diet because of the high mercury content? a. Salmon b. Cod c. Shrimp d. Sword fish

CRITICAL THINKING EXERCISES 1. When interviewing a woman at her first prenatal visit, the nurse asks about her feelings. The woman replies, “I’m frightened and confused. I don’t know whether I want to be pregnant or not. Being pregnant means changing our whole life, and now having somebody to care for all the time. I’m not sure I would be a good mother. Plus I’m a bit afraid of all the changes that would happen to my body. Is this normal? Am I okay?” a. How should the nurse answer this question? b. What specific information is needed to support the client during this pregnancy? 2. Sally, age 23, is 9 weeks pregnant. At her clinic visit she says, “I’m so tired I can barely make it home from work. Then once I’m home, I don’t have the energy to make dinner.” She says she is so sick in the morning that she is frequently late to work and spends much of the day in the bathroom. Sally’s current lab work is within normal limits. a. What explanation can the nurse offer Sally about her discomforts? b. What interventions can the nurse offer to Sally?

3. Bringing a new infant into the family affects the siblings. What strategies can a nurse discuss when a mother asks how to deal with this?

STUDY ACTIVITIES 1. Go to your local health department’s maternity clinic and interview several women regarding their feelings and the bodily changes that have taken place since they became pregnant. Based on your findings, place them into appropriate trimesters of their pregnancy. 2. Search the Internet for information about the psychological changes that occur during pregnancy. Share information from the websites you found with your clinical group. 3. During pregnancy, the plasma volume increases by 50% but the RBC volume increases by only 25% to 33%. This disproportion is manifested as ___________________. 4. When a pregnant woman in her third trimester lies on her back and experiences dizziness and light-headedness, the underlying cause of this is ___________________.

BRINGING IT ALL TOGETHER: CASE STUDY A 22-year-old pregnant client presents to the maternity clinic with a 4-day history of loss of appetite, constipation, and abdominal pain. She is in the first trimester of her first pregnancy and came to this country recently from India. Her mother accompanies her and answers most of the questions for her daughter. After much questioning, the mother reveals that her daughter frequently eats dirt, which is a common practice in her country.

ASSESSMENT Examination reveals a tired-looking young woman, normal vital signs, moist pale mucous membranes, and a moderately distended abdomen. Bowel sounds are slow and faint. The fetal heart rate is within normal range. Go to

to find questions to consider about this case.

12 Nursing Management During Pregnancy

KEY TERMS alpha-fetoprotein amniocentesis biophysical profile (BPP) chorionic villus sampling (CVS) gravida high-risk pregnancy linea nigra natural childbirth para perinatal education preconception care

Learning Objectives Upon completion of the chapter, you will be able to: 1. Relate the information typically collected at the initial prenatal visit. 2. Determine an appropriate reproductive life plan based on a couple’s risk profile. 3. Select the assessments completed at follow-up prenatal visits. 4. Evaluate the tests used to assess maternal and fetal well-being, including nursing management for each. 5. Outline appropriate nursing management to promote maternal self-care and to minimize the common discomforts of pregnancy. 6. Examine the key components of perinatal education. Linda and her husband, Rob, are eager to start a family within the next year. They are stable in their careers and financially secure. They decide to investigate a new nurse–midwife practice associated with the local hospital, and they go for a preconception appointment. They leave their appointment overwhelmed with all the information they were given about having a healthy pregnancy.

Words of Wisdom The secret of human touch is simple: showing a sincere liking and interest in people. Nurses need to use touch often.

INTRODUCTION Pregnancy is a time of many physiologic and psychological changes that can positively or negatively affect the woman, her fetus, and her family. Misconceptions, inadequate information, and unanswered questions about pregnancy, birth, and parenthood are common. The ultimate goal of any pregnancy is the birth of a healthy newborn, and nurses play a major role in helping the pregnant woman and her partner achieve this goal. Ongoing assessment and education are essential. This chapter describes the nursing management required during pregnancy. It begins with a brief discussion of preconception care and then describes the assessment of the woman at the first prenatal visit and on follow-up visits. The chapter discusses tests commonly used to assess maternal and fetal well-being, including specific nursing management related to each test. The chapter also identifies important strategies to minimize the common discomforts of pregnancy and promote self-care. Finally, the chapter discusses perinatal education, including childbirth education, birthing options, health care provider options, preparation for breast-feeding or bottle-feeding, and final preparation for labor and birth.

PRECONCEPTION CARE Ideally, couples thinking about having a child should schedule a visit with their health care provider for preconception counseling to ensure that they are in the best possible state of health before pregnancy. Preconception care is the promotion of the health and well-being of a woman and her partner before pregnancy. The goal of preconception care is to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management interventions (Centers for Disease Control and Prevention [CDC], 2015a). Preconception care is advocated throughout the world as a tool for improving perinatal outcomes. Preconception care should occur any time a health care provider sees a woman of reproductive age. Primary care for all women of childbearing age by nurses should include a routine assessment of a woman’s reproductive goals and planning. Women who could potentially become pregnant should be assessed for preconception risks and educated about the importance of maternal health in ensuring healthy pregnancies. Women may be motivated to address modified health risks by learning about the way their present health will affect a future pregnancy. For women not intending a pregnancy soon, preconception care should focus on contraception counseling (Callegari, Ma, & Schwartz, 2015). Personal and family history, physical examination, laboratory screening, reproductive plan, nutrition, supplements, weight, exercise, vaccinations, and injury prevention should be reviewed in all women. Encourage folic acid 400 to 800 mcg per day depending on risk profile, as well as proper diet and exercise. Women should receive the influenza vaccine if planning pregnancy during flu season; the rubella and varicella vaccines if there is no evidence of immunity to these viruses; and tetanus/diphtheria/pertussis if lacking adult vaccination. Offer specific interventions to reduce morbidity and mortality for both the woman who has been identified with chronic diseases or exposed to teratogens or illicit substances and her baby. Several interventions have been proven to effectively improve pregnancy outcome when provided as preconception care. Recent research suggests that events that occur in the uterine decidua, even before a woman knows she is pregnant, may have a significant impact on fetal growth and the outcome of pregnancy. In addition, an intact immune system optimizes

placental development and function and is essential for fetal survival (Regal, Gilbert, & Burwick, 2015). New insights reveal that the early embryo is extremely sensitive to signals from gametes, trophoblastic tissue, and periconception maternal lifestyles. Also, environmental factors prior to and after conception have an enormous impact on the developing embryo and cause longterm health problems. There is a growing body of evidence that environmental factors during embryonic development can cause irreversible alteration in epigenetic markers and induce various adult diseases, such as cardiovascular, neurologic, and metabolic disorders later in life (Keytash, Jones, & Frances, 2015). With this in mind, shifting the focus on the periconception period and the very early stages of pregnancy should offer significant benefits to the health of both the mother and her infant. The overall aim should be to effectively use every pregnancy as the health care opportunity of two lifetimes (SteeggersTheunissen & Steegers, 2015). The CDC (2015b) formulated 10 guidelines for preconception care (see Box 12.1).

Risk Factors for Adverse Pregnancy Outcomes Preconception care is just as important as prenatal care to reduce adverse pregnancy outcomes such as maternal and infant mortality, preterm births, and low–birth-weight infants. Adverse pregnancy outcomes constitute a major public health challenge: 13% of infants are born premature; 8.3% are born with low birth weight; 1 in 33 live births have major birth defects; and 32% of women suffer pregnancy complications (CDC, 2015c). Risk factors for these adverse pregnancy outcomes are prevalent among women of reproductive age, as demonstrated by the following statistics: • 10% of women smoke during pregnancy, contributing to fetal addiction to nicotine. • 7.6% consume alcohol during pregnancy, leading to fetal alcohol spectrum disorder. • 70% of women do not take folic acid supplements, increasing the risk of neural tube defects in the newborn. Taking folic acid reduces the incidence of neural tube defects by two thirds. • 35% of women starting a pregnancy are obese, which may increase their risk of developing hypertension, diabetes, and thromboembolic disease and may increase the need for cesarean birth. • 3% take prescription or over-the-counter drugs that are known teratogens (substances harmful to the developing fetus). • 5% of women have preexisting medical conditions that can negatively affect pregnancy if unmanaged (CDC, 2015d).

BOX 12.1 TEN GUIDELINES FOR PRECONCEPTION CARE • Recommendation 1. Individual responsibility across the lifespan: Each woman, man, and couple should be encouraged to have a reproductive life plan. • Recommendation 2. Consumer awareness: Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts. • Recommendation 3. Preventive visits: As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes. • Recommendation 4. Interventions for identified risks: Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high-priority interventions (i.e., those with evidence of effectiveness and greatest potential impact). • Recommendation 5. Interconception care: Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birth weight, or preterm birth). • Recommendation 6. Prepregnancy checkup: Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy. • Recommendation 7. Health insurance coverage for women with low incomes: Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care. • Recommendation 8. Public health programs and strategies: Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.

• Recommendation 9. Research: Increase the evidence base and promote the use of the evidence to improve preconception health. • Recommendation 10. Monitoring improvements: Maximize public health surveillance and related research mechanisms to monitor preconception health. Adapted from Centers for Disease Control and Prevention. (2015b). Preconception care recommendations. Retrieved from http://www.cdc.gov/preconception/hcp/recommendations.html

All of the preceding factors pose risks to pregnancy and could be addressed with early interventions if the woman seeks preconception health care. Specific recognized risk factors for adverse pregnancy outcomes that fall into one or more of these categories are listed in Box 12.2. The period of greatest environmental sensitivity and consequent risk for the developing embryo is between days 17 and 56 after conception. The first prenatal visit, which is usually a month or later after a missed menstrual period, may occur too late to affect reproductive outcomes associated with abnormal organogenesis secondary to poor lifestyle choices. In some cases, such as with unplanned pregnancies, women may delay seeking health care because they deny that they are pregnant. Thus, commonly used prevention practices may begin too late to avert the morbidity and mortality associated with congenital anomalies and low birth weight. A more global preventative strategy is needed to reduce the high rates of pregnancy complications in all populations. Securing international-level political priority for maternal and newborn care remains critical to accomplish the goal of better health for all families. All couples should take on the responsibility of developing their reproductive life plan and share it with their health care providers at office visits (Darmstadt, Shiffman, & Lawn, 2015). What is the purpose of couples like Linda and Rob going for preconception counseling? What are the goals of preconception care for this couple? What psychological support can be offered by the nurse to this couple at this stage?

Nursing Management In the United States, rates of maternal mortality, unintended pregnancies, low birth weight, and preterm infants continue to rise, making the need for preconception care a priority for all nurses. Traditionally, women have thought that preconception care is a single visit made before getting pregnant; however, the maximum benefits are obtained when the woman and her partner receive care throughout her reproductive years. The nurse’s role is vital in identifying risk factors and encouraging healthier behaviors that potentially improve maternal and perinatal outcomes. Preconception care involves obtaining a complete health history and physical examination of the woman and her partner. Key areas include: • immunization status of the woman; • underlying medical conditions, such as cardiovascular and respiratory problems or genetic disorders; • reproductive health data, such as pelvic examinations, use of contraceptives, and STIs; • sexuality and sexual practices, such as safer-sex practices and body image issues; • nutrition history and present status; • lifestyle practices, including occupation and recreational activities; • psychosocial issues such as levels of stress and exposure to abuse and violence; • medication and drug use, including use of tobacco, alcohol, over-the-counter and prescription medications, and illicit drugs; • support system, including family, friends, and community.

BOX 12.2 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES • Isotretinoins. Use of isotretinoins (e.g., Accutane®) in pregnancy to treat acne can result in alcohol misuse. No time during pregnancy is safe to drink alcohol, and harm can occur early, before a woman has realized that she is or might be pregnant. Fetal alcohol syndrome and other alcohol-related birth defects can be prevented if women cease intake of alcohol before conception. • Antiepileptic drugs. Certain antiepileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed a lower dosage of these drugs. • Diabetes (preconception). The threefold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes. • Folic acid deficiency. Daily use of vitamin supplements containing folic acid (400 mcg) has been demonstrated to reduce the occurrence of neural tube defects by two thirds. • Hepatitis B. Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants and eliminates risk to the woman of HBV infection and sequelae, including hepatic failure, liver carcinoma, cirrhosis, and death. • HIV/AIDS. If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission. • Rubella seronegativity. Rubella vaccination provides protective seropositivity and prevents congenital rubella syndrome. • Obesity. Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Appropriate weight loss and

nutritional intake before pregnancy reduce these risks. • Sexually transmitted infections (STIs). Chlamydia trachomatis and Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STIs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including intellectual disability and blindness. Early screening and treatment prevent these adverse outcomes. • Smoking. Preterm birth, low birth weight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of women successfully control tobacco dependency during pregnancy, cessation of smoking is recommended before pregnancy. Adapted from Centers for Disease Control and Prevention. (2015a). Preconception care and health care. Retrieved from http://www.cdc.gov/preconception/hcp/; March of Dimes. (2015a). Pregnancy complications.

Retrieved

from

http://www.marchofdimes.com/pregnancy/pregnancy-

complications.aspx; National Institutes of Health. (2015). Health problems in pregnancy. Retrieved from http://www.nlm.nih.gov/medlineplus/healthproblemsinpregnancy.html; Senie, R. T. (2014). Epidemiology of women’s health. Burlington, MA: Jones & Bartlett Learning.

Figure 12.1 gives a sample preconception screening tool. This information provides a foundation for planning health promotion activities and education. For example, to have a positive impact on the pregnancy: • ensure that the woman’s immunizations are up to date; • create a reproductive life plan to address and outline their reproductive needs; • take a thorough history of both partners to identify any medical or genetic conditions that need treatment or a referral to specialists; • identify history of STIs and high-risk sexual practices so they can be modified; • complete a dietary history combined with nutritional counseling; • gather information regarding exercise and lifestyle practices to encourage daily exercise for well-being and weight maintenance; • stress the importance of taking folic acid to prevent neural tube defects; • urge the woman to achieve optimal weight before a pregnancy;

• identify work environment and any needed changes to promote health; • address substance use issues, including smoking and drugs; • identify victims of violence and assist them to get help; • manage chronic conditions such as diabetes and asthma; • educate the couple about environmental hazards, including metals and herbs; • offer genetic counseling to identify carriers; • suggest the availability of support systems, if needed (Hurst & Linton, 2015; Templeton, 2015).

FIGURE 12.1 Sample preconception screening tool. (Used with permission. Copyright March of Dimes.)

Nurses can act as advocates and educators, creating healthy, supportive communities for women and their partners in the childbearing phases of their lives. It is important to enter into a collaborative partnership with the woman and her partner, enabling them to examine their own health and its influence on the health of their future baby. Provide information to allow the woman and her partner to make an informed decision about having a baby, but keep in mind that this decision rests solely with the couple.

Take Note! Because all women of reproductive age, from menarche to menopause, benefit from preventive care, preconception care should be an integral part of that continuum (Boggess & Berggren, 2015). Linda and Rob decide to change several aspects of their lifestyle and nutritional habits before conceiving a baby, based on advice from the nursemidwife. They both want to lose weight, stop smoking, and increase their intake of fruits and vegetables. How will these lifestyle and dietary changes benefit Linda’s future pregnancy? What other areas might need to be brought up to date to prepare for a future pregnancy?

THE FIRST PRENATAL VISIT Once a pregnancy is suspected and, in some cases, tentatively confirmed by a home pregnancy test, the woman should seek prenatal care to promote a healthy outcome. Although the most opportune window (preconception) for improving pregnancy outcomes may be missed, appropriate nursing management starting at conception and continuing throughout the pregnancy can have a positive impact on the health of pregnant women and their unborn children. The assessment process begins at this initial prenatal visit and continues throughout the pregnancy. The initial visit is an ideal time to screen for factors that might place the woman and her fetus at risk for problems such as preterm delivery. The initial visit also is an optimal time to begin educating the client about changes that will affect her life. Prenatal care can be delivered in one of the two methods: individually or in a group format termed centering. The first method is the traditional model whereby a pregnant woman sees her health care provider at specified interims throughout her pregnancy and all visits occur on a one-to-one basis. The centering pregnancy model of group prenatal care involves groups of up to a dozen women in similar gestational ages meeting with their health care provider for 10 sessions of approximately 1.5 to 2 hours each. The centering group method has been theorized to produce better birth outcomes than traditional individually delivered prenatal care due to increased client–provider interaction, increased social support, and greater perceived empowerment (Tracy, 2014). See Evidence-Based Practice 12.1. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently issued recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Specific recommendations for diagnosing hyperglycemic disorders in pregnancy include the following: • At the first prenatal visit, measure fasting plasma glucose, HbA1c, or random plasma glucose of all women or all high-risk women based on her risk factors, weight status, and family history. Thresholds for diagnosis of overt diabetes during pregnancy are shown in Box 12.3. • If glucose testing is not diagnostic of overt diabetes, the woman should be tested for gestational diabetes from 24 to 28 weeks of gestation with a 2-hour 75-g oral glucose tolerance test (American Diabetes Association [ADA],

2015). Given our society’s poor food choices, sedentary tendencies, obesity, increasing life stresses, and the increasing immigration of high-risk populations (Hispanic, African American, Southeast Asian, Arab, Afro-Caribbean, Mediterranean, and Native American), the incidence of gestational diabetes is growing. The American College of Obstetricians and Gynecologists (ACOG), the American Diabetes Association (ADA), and the World Health Organization (WHO) have all recommended screening at the first prenatal visit for women who are over 25 years old, overweight, have polycystic ovary syndrome, history of gestational diabetes, and a positive family history of diabetes (Satyan et al., 2015). Global guidelines for screening, diagnosis, and classification have been established, and offer the potential to stop the cycle of diabetes and obesity caused by hyperglycemia in pregnancy. Normoglycemia is the goal in all aspects of pregnancy and offers the benefits of decreased short-term and long-term complications of diabetes.

BOX 12.3 THRESHOLDS FOR DIAGNOSIS OF OVERT DIABETES DURING PREGNANCY The thresholds for the diagnosis of overt diabetes during pregnancy are: • Fasting plasma glucose: 126 mg/dL • Hemoglobin A1c level: at least 6.5% • Random plasma glucose: 200 mg/dL

EVIDENCE-BASED PRACTICE 12.1 THE EFFECTS OF CENTERING PREGNANCY GROUP PRENATAL CARE ON GESTATIONAL AGE, BIRTH WEIGHT, AND FETAL DEMISE

STUDY Although rates of infant mortality in the United States have declined over the last several decades, rates of preterm births (25 years old, family history of diabetes, history of gestational diabetes, or woman is of a certain ethnic group: Hispanic, Native Americans, Asian, or African American) (U.S. Preventive Services Task Force [USPSTF], 2015). Between weeks 24 and 28, a blood glucose level is obtained using an oral 50-g glucose load followed by a 1-hour plasma glucose determination. If the result is more than 130 (ADA) to140 (ACOG) mg/dL, further testing, such as a 3-hour 100-g glucose tolerance test, is warranted to determine whether gestational diabetes is present (Farrar et al., 2015). Because insulin resistance increases as pregnancy advances, testing at this gestational point yields a higher rate of abnormal test results. During this time, review the common discomforts of pregnancy, evaluate any client complaints, and answer questions. Reinforce the importance of good nutrition and use of prenatal vitamins, along with daily exercise. Between 29 and 36 weeks gestation, all the assessments of previous visits are completed, along with assessment for edema. Special attention is focused on the presence and location of edema during the last trimester. Pregnant women commonly experience dependent edema of the lower extremities from constriction of blood vessels secondary to the heavy gravid uterus. Periorbital edema around the eyes, edema of the hands, and pretibial edema (edema on the front, or shin part of the leg) are abnormal and could be signs of gestational hypertension. Inspecting and palpating both extremities, listening for complaints of tight rings on fingers, and observing for swelling around the eyes are important assessments. Abnormal findings in any of these areas need to be

reported. If the mother is Rh negative, her antibody titer is evaluated. RhoGAM is given if indicated. RhoGAM is used to prevent development of antibodies to Rh+ red cells whenever fetal cells are known or suspected of entering the maternal circulation such as after a spontaneous abortion or amniocentesis. It is also recommended for prophylaxis at 28 weeks gestation and following birth if the infant is Rh+ (King et al., 2015). The client also is evaluated for risk of preterm labor. At each visit, ask if she is experiencing any common signs or symptoms of preterm labor (e.g., uterine contractions, dull backache, feeling of pressure in the pelvic area or thighs, increased vaginal discharge, menstrual-like cramps, vaginal bleeding). If the woman has had a previous preterm birth, she is at risk for another and close monitoring is warranted. An initial preterm labor evaluation if the woman reports signs and symptoms of preterm labor includes: review of prenatal record for risk factors, evaluation of reported symptoms (uterine contractions, vital signs, fetal heart rate, pelvic exam for cervical dilation and effacement assessment, and status of fetal membranes), and a urine culture to diagnose asymptomatic bacteriuria (Jordan et al., 2014). If positive for preterm labor, the woman may be requested to rest and medications to stop contractions may be in order. Counsel the woman about choosing a health care provider for the newborn, if she has not selected one yet. Along with completion of a breast assessment, the nurse should discuss and educate the client about the choice of breast-feeding versus bottle-feeding. The American Academy of Pediatrics (AAP) does encourage all mothers to breast-feed their offspring, but the decision to do so is the woman’s ultimately. The nurse can refer the client to Nursing Mothers and La Leche League web sites for further information to assist her in making that decision. Reinforce the importance of daily fetal movement monitoring as an indicator of fetal well-being. Re-evaluate hemoglobin and hematocrit levels to assess for anemia. Between 37 and 40 weeks gestation, the same assessments are done as for the previous weeks. In addition, screening for group B streptococcus, gonorrhea, and chlamydia is done. Fetal presentation and position (via Leopold’s maneuvers) are assessed. Review the signs and symptoms of labor and forward a copy of the prenatal record to the hospital labor department for future reference. Review the client’s desire for family planning after birth as well as her decision to breastfeed or bottle-feed. Remind the client that an infant car seat is required by law and must be used to drive the newborn home from the hospital or birthing center.

Fundal Height Measurement Fundal height is the distance (in centimeters) measured with a tape measure from the top of the pubic bone to the top of the uterus (fundus) with the client lying on her back with her knees slightly flexed (Fig. 12.5). Measurement in this way is termed the McDonald’s method. Fundal height typically increases as the pregnancy progresses; it reflects fetal growth and provides a gross estimate of the duration of the pregnancy. Between 12 and 14 weeks gestation, the fundus can be palpated above the symphysis pubis. The fundus reaches the level of the umbilicus at approximately 20 weeks and measures 20 cm. Fundal measurement should approximately equal the number of weeks of gestation until week 36. For example, a fundal height of 24 cm suggests a fetus at 24 weeks gestation. After 36 weeks, the fundal height then drops due to lightening and may no longer correspond with the week of gestation. It is expected that the fundal height will increase progressively throughout the pregnancy, reflecting fetal growth. However, if the growth curve flattens or stays stable, it may indicate the presence of FGR. If the fundal height measurement is greater than 4 cm from the estimated gestational age, further evaluation is warranted if a multifetal gestation has not been diagnosed or hydramnios has not been ruled out (Weber & Kelley, 2014).

FIGURE 12.5 Fundal height measurement.

Fetal Movement Determination Perception of fetal movement typically begins in the second trimester, and occurs earlier in multiparous women versus nulliparous women. The mother’s first perception of fetal movement, termed “quickening,” is commonly described as a gentle fluttering. This perceived fetal movement is most often related to trunk and limb motion and rollovers, or flips (Moses, 2015b). Maternal perception of fetal movement is an important screening method for fetal wellbeing, because decreased fetal movement is associated with a range of pregnancy pathologies and poor pregnancy outcomes. Decreased fetal movement may indicate asphyxia and FGR. If compromised, the fetus decreases its oxygen requirements by decreasing activity. Reduced fetal movement is thought to represent fetal compensation in a chronic hypoxic environment due to inadequacies in the placental supply of oxygen and nutrients (Fretts, 2014). A decrease in fetal movement may also be related to other factors as well, such as maternal use of central nervous system depressants, fetal sleep cycles, hydrocephalus, bilateral renal agenesis, stillbirth, placental dysfunction, and bilateral hip dislocation (Heazell, 2015). Fetal movement counting is a method used by the mother to quantify her fetus’s movement. However, the optimal number of movements and the ideal duration of counting them remain controversial. Many variations for determining fetal movement, also called fetal movement counts, have been developed, but the one most common method is described as follows. Determining fetal movement is a noninvasive method of screening and can be easily taught to all pregnant women. Any technique used requires client participation and cooperation. Instruct the client about how to count fetal movements, the reasons for doing so, and the significance of decreased fetal movements. Urge the client to perform the counts in a relaxed environment and a comfortable position, such as semiFowler’s or side-lying. Provide the client with detailed information concerning fetal movement counts and stress the need for consistency in monitoring (at approximately the same time each day) and the importance of informing the health care provider promptly of any reduced movements. Providing clients with “fetal kick count” charts to record movement helps promote adherence to your instructions. No values for fetal movement have been established that indicate fetal well-being, so the woman needs to be aware of a decrease in the number of movements when last assessed. The most common method used is “Count to

10,” whereby a woman focuses her attention on her fetus’s movement and records how long it takes to document 10 movements. If it takes longer than 2 hours, the woman should contact her health care provider for further evaluation. Fetal kick counting in current prenatal care appears to be underutilized and nurses need to educate women about this assessment in their pregnancy care.

Fetal Heart Rate Measurement Fetal heart rate measurement is integral to fetal surveillance throughout the pregnancy. Auscultating the fetal heart rate with a handheld Doppler at each prenatal visit helps confirm that the intrauterine environment is still supportive to the growing fetus. The purpose of assessing fetal heart rate is to determine the rate and rhythm. The normal fetal heart rate range is 110 to 160 bpm. Nursing Procedure 12.1 lists the steps in measuring fetal heart rate.

NURSING PROCEDURE 12.1

Measuring Fetal Heart Rate Purpose: To Assess Fetal Well-Being 1. Assist the woman onto the examining table and have her lie down. 2. Cover her with a sheet to ensure privacy, and then expose her abdomen. 3. Palpate the abdomen to determine the fetal lie, position, and presentation. 4. Locate the back of the fetus (the ideal position to hear the heart rate). 5. Apply lubricant gel to abdomen in the area where the back has been located. 6. Turn on the handheld Doppler device and place it on the spot over the fetal back. 7. Listen for the sound of the amplified heart rate, moving the device slightly from side to side as necessary to obtain the loudest sound. Assess the woman’s pulse rate and compare it to the amplified sound. If the rates appear the same, reposition the Doppler device. 8. Once the fetal heart rate has been identified, count the number of beats in 1 minute and record the results. 9. Remove the Doppler device and wipe off any remaining gel from the woman’s abdomen and the device. 10. Record the heart rate on the woman’s medical record; normal range is 110 to 160 bpm. 11. Provide information to the woman regarding fetal well-being based on findings.

Teaching About the Danger Signs of Pregnancy It is important to educate the client about danger signs during pregnancy that require further evaluation. Explain that she should contact her health care provider immediately if she experiences any of the following: • During the first trimester: spotting or bleeding (miscarriage), painful urination (infection), severe persistent vomiting (hyperemesis gravidarum), fever >100 °F (37.7 °C; infection), and lower abdominal pain with dizziness and accompanied by shoulder pain (ruptured ectopic pregnancy) • During the second trimester: regular uterine contractions (preterm labor); pain in calf, often increased with foot flexion (blood clot in deep vein); sudden gush or leakage of fluid from vagina (premature rupture of membranes); and absence of fetal movement for more than 12 hours (possible fetal distress or demise) • During the third trimester: sudden weight gain; periorbital or facial edema, severe upper abdominal pain, or headache with visual changes (gestational hypertension and/or preeclampsia); and a decrease in fetal daily movement for more than 24 hours (possible demise). Any of the previous warning signs and symptoms can also be present in this last trimester (March of Dimes, 2015a).

Early Contractions One of the warning signs that should be emphasized is early contractions, which can lead to preterm birth. The woman should not confuse these early preterm contractions with Braxton Hicks contractions, which are not true labor pains because they go away when walking around or resting. They often go away when the woman goes to sleep. Braxton Hicks contractions are usually felt in the abdomen versus in the lower back with true preterm labor contractions. Signs of preterm labor that a woman may experience include contractions every 10 minutes or more frequently, change in vaginal discharge, pelvic pressure, low, dull backache, pelvic cramps, and diarrhea (Nagtalon-Ramos, 2014). All pregnant women need to be able to recognize early signs of contractions to prevent preterm labor, which is a major public health problem in the United States. Approximately 12% of all live births—or one out of nine infants —is born too soon. Our nation’s rate of premature births has increased by 36% over the last 25 years. Worldwide, 15 million infants are born too soon each year

(March of Dimes, 2015b). These preterm infants (born at less than 37 weeks gestation) can suffer lifelong health consequences such as intellectual disability, chronic lung disease, cerebral palsy, seizure disorders, and blindness (March of Dimes, 2015c). Preterm labor can happen to any pregnant women at any time. In many cases it can be stopped with medications if it is recognized early, before significant cervical dilation has taken place. If the woman experiences menstrual-like cramps occurring every 10 minutes accompanied by a low, dull backache, she should stop what she is doing and lie down on her left side for 1 hour and drink two or three glasses of water. If the symptoms worsen or do not subside after 1 hour, she should contact her health care provider.

ASSESSMENT OF FETAL WELL-BEING During the antepartum period, several tests are performed routinely to monitor fetal well-being and to detect possible problems. When a high-risk pregnancy is identified, additional antepartum testing can be initiated to promote positive maternal, fetal, and neonatal outcomes. High-risk pregnancies include those that are complicated by maternal or fetal conditions (coincidental with or unique to pregnancy) that jeopardize the health status of the mother and put the fetus at risk for uteroplacental insufficiency, hypoxia, and death (CDC, 2015d). However, additional antepartum fetal testing should take place only when the results obtained will guide future care, whether it is reassurance, more frequent testing, admission to the hospital, or the need for immediate delivery (Brown, 2015).

Ultrasonography Since its introduction in the late 1950s, ultrasonography has become a very useful diagnostic tool in obstetrics. Real-time scanners can produce a continuous picture of the fetus on a monitor screen. A transducer that emits high-frequency sound waves is placed on the mother’s abdomen and moved to visualize the fetus (Fig. 12.6). The fetal heartbeat and any malformations in the fetus can be assessed and measurements can be made accurately from the picture on the monitor screen. Obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve pregnancy outcomes. Because the ultrasound procedure is noninvasive, it is a safe, but not evidence-based practice for low-risk women, accurate, and cost-effective tool. It provides important information about fetal activity, growth, and gestational age; assesses fetal well-being; and determines the need for invasive intrauterine tests (Maeda, 2015). There are no hard-and-fast rules as to the number of ultrasounds a woman should have during her pregnancy. A low-risk woman does not necessarily require any, but most practices do them as part of their prenatal care routine. A transvaginal ultrasound may be performed in the first trimester to confirm pregnancy, exclude ectopic (in which a fertilized egg implants somewhere other than the main cavity of the uterus) or molar (hydatidiform mole, a benign tumor that develops in the uterus) pregnancies, and confirm cardiac pulsation. A second abdominal scan may be performed at about 18 to 20 weeks to look for congenital malformations, exclude multifetal pregnancies, and verify dates and growth. A third abdominal scan may be done at around 34 weeks to evaluate fetal size, assess fetal growth, and verify placental position (Everett & Peebles, 2015). An ultrasound is used to confirm placental location during amniocentesis and to provide visualization during chorionic villus sampling (CVS). An ultrasound is also ordered whenever an abnormality is suspected.

FIGURE 12.6 Ultrasound. A. Ultrasound device being applied to client’s abdomen. B. View of monitor.

During the past several years, ultrasound technology has advanced significantly. Now available for expecting parents is 3D/4D ultrasound imaging. Unlike traditional 2D imaging, which takes a look at the developing fetus from one angle (thus creating the “flat” image), 3D imaging takes a view of the fetus from three different angles. Software then takes these three images and merges them to produce a 3D image. Because the fourth dimension is time and movement, with 4D parents are able to watch the live movements of their fetus in 3D. Nursing management during the ultrasound procedure focuses on educating the woman about the ultrasound test and reassuring her that she will not experience any sensation from the sound waves during the test. No special client preparation is needed before performing the ultrasound, although in early pregnancy the woman may need to have a full bladder. Inform her that she may experience some discomfort from the pressure on the full bladder during the scan, but it will last only a short time. Tell the client that the conducting gel used on the abdomen during the scan may feel cold initially.

Doppler Flow Studies Comprehensive assessment of fetal well-being involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques forms the foundation of prenatal diagnosis of structural anomalies, rhythm abnormalities, and altered fetal circulation (Pruetz, VotavaSmith, & Miller, 2015). Doppler flow studies can be used to measure the velocity of blood flow via ultrasound. Doppler flow studies can detect fetal compromise in high-risk pregnancies. The test is noninvasive and has no contraindications. The color images produced help to identify abnormalities in diastolic flow within the umbilical vessels. The velocity of the fetal red blood cells can be determined by measuring the change in the frequency of the sound wave reflected off the cells. Thus, Doppler flow studies can detect the movement of red blood cells in vessels (Everett & Peebles, 2015). In pregnancies complicated by hypertension or FGRs, diastolic blood flow may be absent or even reversed (Alfirevic, Stampalija, & Medley, 2015). Doppler flow studies also can be used to evaluate the blood flow through other fetal blood vessels, such as the aorta and those in the brain. Research continues to determine the indications for Doppler flow studies to improve pregnancy outcomes. Nursing management of the woman undergoing Doppler flow studies is similar to that described for an ultrasound.

Alpha-Fetoprotein Analysis Alpha-fetoprotein (AFP) is a glycoprotein produced initially by the yolk sac and fetal gut, and later predominantly by the fetal liver. In a fetus, the serum AFP level increases until approximately 14 to 15 weeks, and then falls progressively. In normal pregnancies, AFP from fetal serum enters the amniotic fluid (in microgram quantities) through fetal urination, fetal gastrointestinal secretions, and transudation across fetal membranes (amnion and placenta). About 30 years ago, elevated levels of maternal serum AFP or amniotic fluid AFP were first linked to the occurrence of fetal neural tube defects. This biomarker screening test is now recommended for all pregnant women along with other prenatal screening test depending on risk profile (ACOG, 2015b; Alexander et al., 2014). AFP is present in amniotic fluid in low concentrations between 10 and 14 weeks of gestation and can be detected in maternal serum beginning at approximately 12 to 14 weeks of gestation (Callahan, 2016). If a developmental defect is present, such as failure of the neural tube to close, more AFP escapes into amniotic fluid from the fetus. AFP then enters the maternal circulation by crossing the placenta, and the level in maternal serum can be measured. The optimal time for AFP screening is 16 to 18 weeks of gestation. Currently, ACOG recommends offering screening and diagnostic tests to all pregnant women, regardless of age or risk factors present (2015b). Correct information about gestational dating, maternal weight, race, number of fetuses, and insulin dependency is necessary to ensure the accuracy of this screening test. If incorrect maternal information is submitted or the blood specimen is not drawn during the appropriate time frame, false-positive results may occur, increasing the woman’s anxiety. Subsequently, further testing might be ordered based on an inaccurate interpretation, resulting in additional financial and emotional costs to the woman. A variety of situations can lead to elevation of maternal serum AFP, including open neural tube defect, underestimation of gestational age, the presence of multiple fetuses, gastrointestinal defects, low birth weight, oligohydramnios, maternal age, diabetes, and decreased maternal weight (King et al., 2015). Lower-than-expected maternal serum AFP levels are seen when fetal gestational age is overestimated or in cases of fetal death, hydatidiform mole, increased maternal weight, maternal type 1 diabetes, and fetal trisomy 21 (Down syndrome) or trisomy 18 (Edward’s syndrome) (Khalil & Coates, 2015).

Measurement of maternal serum AFP is minimally invasive, requiring only a venipuncture for a blood sample. AFP has now been combined with other biomarker screening tests to determine the risk of neural tube defects and Down syndrome. Nursing management for AFP testing consists of preparing the woman for this screening test by gathering accurate information about the date of her LMP, weight, race, and gestational dating. Accurately determining the window of 16 to 18 weeks gestation will help to ensure that the test results are correct. Also explain that the test involves obtaining a blood specimen.

Marker Screening Tests Using maternal serum is an effective, noninvasive method for identifying fetal risk for aneuploidy (trisomies 13, 18, and 21) and neural tube defects. Prenatal screening for Down syndrome in the early second trimester with multiple maternal serum markers has been available for more than 15 years. Abnormalities in maternal serum marker levels and fetal measurements obtained during the first trimester screening can be markers for not only certain chromosomal disorders and anomalies in the fetus, but also for specific pregnancy complications. Pregnancy-associated plasma protein A (PAPP-A) is a key regulator of insulin-like growth factor essential for normal fetal development. In maternal blood, this protein increases with gestational age. It is routinely used for Down syndrome screening in the first trimester. A low maternal serum PAPP-A, at 11 to 13 weeks of gestation, is associated with stillbirth, infant death, preterm birth, preeclampsia, and chromosomal abnormalities (Kalousová, Muravská, & Zima, 2014; Patil, Panchanadikar, & Wagh, 2014). Multiple blood screening tests may be used to determine the risk of open neural tube defects and Down syndrome: the triple-marker screen (AFP, hCG, and unconjugated estriol) or the quad screen, which includes the triple screening tests with the addition of a fourth marker, inhibin A (glycoprotein secreted by the placenta). The quad screen is used to enhance the accuracy of screening for Down syndrome in women younger than 35 years of age. Low inhibin A levels indicate the possibility of Down syndrome (ACOG, 2015b). These biomarkers are merely screening tests and identify women who need further definitive procedures (i.e., ultrasound, amniocentesis, and genetic counseling) to make a diagnosis of neural tube defects (anencephaly, spina bifida, and encephalocele) or Down syndrome in the fetus. Most screening tests are performed between 15 and 22 weeks of gestation (16 to 18 weeks is ideal), except for the cffDNA test which can be performed around 9 to 10 weeks gestation (Dempsey & Overton, 2015). With these multiple screening tests, low maternal serum AFP (MSAFP), unconjugated estriol levels, and a high hCG level suggest the possibility of Down syndrome. Elevated levels of MSAFP are associated with open neural tube defects, ventral wall defects, some renal abnormalities, multiple gestation, certain skin disorders, fetal demise, and placental abnormality. The multiple marker combination with the highest screening performance currently available

is AFP, unconjugated estriol (uE3), hCG, and inhibin A, together with maternal age (the so-called quad marker test). With this combination, a detection rate of 80% at a 5% false-positive rate is achieved (Hixson et al., 2015). A number of factors influence the interpretation of an MSAFP value. The most important is the accuracy of the gestational age determination. A variation of 2 weeks can be misleading and lead to a wrong interpretation. Maternal weight (>250 pounds), ethnicity, maternal smoking habits, fetal gender, gravidity, para status, and women with insulin-dependent diabetes also may alter the levels of MSAFP and need to be taken into consideration when interpreting the results (Latendresse & Deneris, 2015). Recent research studies indicate prenatal testing with the use of cell free DNA (cfDNA) has significantly lower false positives and high positive predictive values for detection of trisomies than standard testing (Greeley, Kessler, & Vohra, 2015).

Nursing Management Accurate test interpretation and risk determination are dependent on accurate pregnancy dating and reporting of relevant maternal characteristics. This is why it is so important for nurses, if an abnormal test result is reported, for them to confirm pregnancy dating and report any significant maternal factors relevant to test accuracy. In addition, nurses have a big role in providing education about the tests to the couples. Prenatal screening has become standard in prenatal care. However, for many couples it remains confusing, emotionally charged, and filled with uncertain risks. Offer a thorough explanation of the test, reinforcing the information given by the health care professional. Provide couples with a description of the risks and benefits of performing these screens, emphasizing that these tests are for screening purposes only. Remind the couple that a definitive diagnosis is not made without further tests such as an amniocentesis. Answer any questions about these prenatal screening tests and respect the couple’s decision if they choose not to have them done. Many couples may choose not to know because they would not consider having an abortion regardless of the test results.

Nuchal Translucency Screening Nuchal translucency screening (ultrasound) is also done in the first trimester between 11 and 14 weeks. This allows for early detection and diagnosis of some fetal chromosomal and structural abnormalities. Over the years, it has become clear that increased nuchal translucency is a marker for chromosomal abnormalities, and is also associated with a wide spectrum of structural anomalies, genetic syndromes, and high risk of abortion and fetal death (Rayburn, Jolley, & Simpson, 2015). Ultrasound is used to identify an increase in nuchal translucency, which is due to the subcutaneous accumulation of fluid behind the fetal neck. Increased nuchal translucency is associated with chromosomal abnormalities such as trisomies 21, 18, and 13. Infants with trisomies tend to have more collagen and elastic connective tissue, allowing for accumulation. In addition, diaphragmatic hernias, cardiac defects, and fetal skeletal and neurologic abnormalities have been associated with increased nuchal translucency measurements (Evans, Andriole, & Evans, 2015). See Chapter 10 for more information.

Amniocentesis Amniocentesis involves a transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid for analysis. The fluid contains fetal cells that are examined to detect chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth. In addition, amniocentesis is used to confirm a fetal abnormality when other screening tests detect a possible problem. Amniocentesis is performed in the second trimester, usually between 15 and 18 weeks gestation. At this age, the amount of fluid is adequate (approximately 150 mL), and the ratio of viable to nonviable cells is the greatest (Hehir, Dalrymple, & Malone, 2015). More than 40 different chromosomal abnormalities, inborn errors of metabolism, and neural tube defects can be diagnosed with amniocentesis. It can replace a genetic probability with a diagnostic certainty, allowing the woman and her partner to make an informed decision about the option of therapeutic abortion. Amniocentesis can be performed in any of the three trimesters of pregnancy. An early amniocentesis (performed between weeks 11 and 14) is done to detect genetic anomalies. However, early amniocentesis has been associated with a high risk of spontaneous miscarriage and postprocedural amniotic fluid leakage compared with transabdominal chorionic villus screening (King et al., 2015). In the second trimester, the procedure is performed between 15 and 20 weeks to detect chromosomal abnormalities, evaluate the fetal condition when the woman is sensitized to the Rh-positive blood, diagnose intrauterine infections, and investigate amniotic fluid AFP when the MSAFP level is elevated (March of Dimes, 2015d). In the third trimester, amniocentesis is most commonly indicated to determine fetal lung maturity after the 35th week of gestation via analysis of lecithin-tosphingomyelin ratios and to evaluate the fetal condition with Rh isoimmunization. Table 12.2 lists amniotic fluid analysis findings and their implications.

Procedure Amniocentesis is performed after an ultrasound examination identifies an adequate pocket of amniotic fluid free of fetal parts, the umbilical cord, or the placenta (Fig. 12.7). The health care provider inserts a long pudendal or spinal

needle, a 22-gauge, 5-inch needle, into the amniotic cavity and aspirates amniotic fluid, which is placed in an amber or foil-covered test tube to protect it from light. When the desired amount of fluid has been withdrawn, the needle is removed and slight pressure is applied to the site. If there is no evidence of bleeding, a sterile bandage is applied to the needle site. The specimens are then sent to the laboratory immediately for the cytologist to evaluate. Examining a sample of fetal cells directly produces a definitive diagnosis rather than a “best guess” diagnosis based on indirect screening tests. It is an invaluable diagnostic tool, but the risks include lower abdominal discomfort and cramping that may last up to 48 hours after the procedure, spontaneous abortion (1 in 200), maternal or fetal infection, postamniocentesis chorioamnionitis that has an insidious onset, fetal–maternal hemorrhage, leakage of amniotic fluid in 2% to 3% of women after the procedure, and higher rates of fetal loss in earlier amniocentesis procedures (24 hours), moderate hypertension (>150/100), confirmed delay in the first or second stage of labor; and the presence of meconium (National Institute for Health and care Excellence [NICE], 2014). Electronic fetal monitoring (EFM) uses a machine to produce a continuous tracing of the FHR. When the monitoring device is in place, a sound is produced with each heartbeat. In addition, a graphic record of the FHR pattern is produced. The primary objective of EFM is to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor. The purpose of EFM is to detect FHR changes early before they are prolonged and profound. Fetal hypoxia is demonstrated in a heart rate pattern change and is by far the most common etiology of fetal injury and death that can be prevented with optimal fetal surveillance during labor and early interventions (Cox & King, 2015). Current methods of continuous EFM were introduced in the United States during the 1970s, specifically for use in clients considered to be at high risk. However, the use of these methods gradually increased and they eventually came to be used for women other than just those at high risk. This increased use has become controversial because it is suspected of being associated with the steadily increasing rates of cesarean births with no decrease in the rate of cerebral palsy (Omo-Aghoja, 2015). Many studies suggest that when compared with standardized intermittent auscultation, the use of intrapartum continuous EFM seems to increase the number of preterm and surgical births but has no significant effect on reducing the incidence of intrapartum death or long-term neurologic injury. When a woman is admitted to the labor unit, a fetal monitor is applied and the FHR is monitored continuously. An impetus for this is the litigious nature of current society, but the benefits have not been proven scientifically. EFM has been given excessive importance in legal cases. Before assigning fault on events at birth, a better understanding of developmental neurobiology and limitations of the present biomarkers is warranted (Freeman, 2015). To date, continuous EFM is not evidence-based for determining fetal health status. With EFM, there is a continuous record of the FHR: no gaps exist, as they do with intermittent auscultation. The concept of hearing and evaluating every beat of the fetus’s heart to allow for early intervention seems logical. On the downside, however, using continuous monitoring can limit maternal movement and encourages the woman to lie in the supine position, which reduces placental

perfusion. Despite the criticisms, EFM remains an accurate method for determining fetal health status by providing a moment-to-moment printout of FHR status. Various groups within the medical community have criticized the use of continuous fetal monitoring for all pregnant clients, whether high risk or low risk. Concerns about the efficiency and safety of routine EFM in labor have led expert panels in the United States to recommend that such monitoring be limited to high-risk pregnancies. However, its use in low-risk pregnancies continues globally (Maso et al., 2015). This remains an important research issue. Continuous EFM can be performed externally (indirectly), with the equipment attached to the maternal abdominal wall, or internally (directly), with the equipment attached to the fetus. Both methods provide a continuous printout of the FHR, but they differ in their specificity. The efficacy of EFM depends on the accurate interpretation of the tracings, not necessarily which method (external vs. internal) is used. CONTINUOUS EXTERNAL MONITORING In external or indirect monitoring, two ultrasound transducers, each of which is attached to a belt, are applied around the woman’s abdomen. They are similar to the handheld Doppler device. One transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus. It detects changes in uterine pressure and converts the pressure registered into an electronic signal that is recorded on graph paper (Farine, 2015). The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. It is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The diaphragm of the ultrasound transducer is moved to either side of the abdomen to obtain a stronger sound and is then attached to the second elastic belt. This transducer converts the fetal heart movements into beeping sounds and records them on graph paper (Fig. 14.5).

FIGURE 14.5 Continuous external electronic fetal monitoring device applied to the woman in labor.

Good continuous data are provided on the FHR. External monitoring can be used while the membranes are still intact and the cervix is not yet dilated, but also can be used with ruptured membranes and a dilating cervix. It is noninvasive and can detect relative changes in abdominal pressure between uterine resting tone and contractions. External monitoring also measures the approximate duration and frequency of contractions, providing a permanent record of FHR (Casanova, 2015). However, external monitoring can restrict the mother’s movements. It also cannot detect short-term variability. Signal disruptions can occur due to maternal obesity, fetal malpresentation, and fetal movement as well as by artifact. The term artifact is used to describe irregular variations or absence of the FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference. For instance, the monitor may pick up transmissions from citizen’s band (CB) radios used by truck drivers on nearby roads and translate them into a signal. Additionally, gaps in the monitor strip can occur periodically without explanation. CONTINUOUS INTERNAL MONITORING Continuous internal monitoring is usually indicated for women or fetuses considered to be at high risk. Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. It involves the placement of a spiral

electrode into the fetal presenting part, usually the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions (Fig. 14.6). The fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus (Nageotte, 2015). Specially trained labor and birth nurses are permitted to place the spiral electrode on the fetal head when the membranes rupture to assess the FHR in some health care facilities, but they do not place the intrauterine pressure catheter in the uterus. Internal monitoring does not have to include both an intrauterine pressure catheter and a scalp electrode. A fetal scalp electrode can be used to monitor the fetal heartbeat without monitoring the maternal intrauterine pressure.

FIGURE 14.6 Continuous internal electronic fetal monitoring.

Both the FHR and the duration and interval of uterine contractions are recorded on the graph paper. This method permits evaluation of baseline heart rate and changes in rate and pattern. Four specific criteria must be met for this type of monitoring to be used: • Ruptured membranes • Cervical dilation of at least 2 cm • Presenting fetal part low enough to allow placement of the scalp electrode

• Skilled practitioner available to insert spiral electrode (ICSI, 2015b) Compared with external monitoring, continuous internal monitoring can accurately detect both short-term (moment-to-moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. In addition, maternal position changes and movement do not interfere with the quality of the tracing.

Determining FHR Patterns Due to the rising costs of litigations related to birth asphyxia of the newborn and increasing complexity of obstetric populations, it has become absolutely mandatory that all nurses responsible for the care of women in labor are trained adequately in interpretation and documentation of CTG tracings, as well as the guidelines for interventions based on the assessment of the tracing and overall clinical situation. Assessment parameters of the FHR include baseline FHR and variability, presence of accelerations, periodic or episodic decelerations, and changes or trends of FHR patterns over time. The nurse must be able to interpret the various parameters to determine if the FHR pattern is a category I, which is strongly predictive of normal fetal acid–base status at the time of observation and needs no intervention; a category II, which is not predictive of abnormal fetal acid–base status and but does require evaluation and continued monitoring; or a category III, which is predictive of abnormal fetal acid–base status at the time of observation and requires prompt evaluation and interventions, such as giving maternal oxygen, changing maternal position, discontinuing labor augmentation medication, and/or treating maternal hypotension (Freeman, 2015). Table 14.1 summarizes these categories. BASELINE FHR Baseline fetal heart rate refers to the average FHR that occurs during a 10minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes. The normal baseline FHR ranges between 110 and 160 beats per minute (bpm) (National Institute of Child Health and Human Development [NICHD], 2015). The normal baseline FHR can be obtained by auscultation, ultrasound, or Doppler, or by a continuous internal direct fetal electrode. Fetal bradycardia occurs when the FHR is below 110 bpm and lasts 10

minutes or longer (Maso et al., 2015). It can be the initial response of a healthy fetus to asphyxia. Causes of fetal bradycardia might include fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block (Nageotte, 2015). Bradycardia may be benign if it is an isolated event, but it is considered an ominous sign when accompanied by a decrease in baseline variability and late decelerations. Fetal tachycardia is a baseline FHR greater than 160 bpm that lasts for 10 minutes or longer (NICHD, 2015). It can represent an early compensatory response to asphyxia. Other causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal dehydration, amnionitis, drugs (e.g., cocaine, amphetamines, nicotine), maternal hyperthyroidism, maternal anxiety, fetal anemia, prematurity, fetal infection, chronic hypoxemia, congenital anomalies, fetal heart failure, and fetal arrhythmias. Fetal tachycardia is considered an ominous sign if it is accompanied by a decrease in variability and late decelerations (Yuan, 2015). TABLE 14.1 Interpreting FHR Patterns

BASELINE VARIABILITY Baseline variability is defined as irregular fluctuations in the baseline fetal heart rate, which is measured as the amplitude of the peak to trough in bpm (Sholapurkar, 2015). It represents the interplay between the parasympathetic and sympathetic nervous systems. The constant interplay (push-and-pull effect) on the FHR from the parasympathetic and sympathetic systems produces a momentto-moment change in the FHR. Because variability is in essence the combined result of autonomic nervous system branch function, its presence implies that the both branches are working and receiving adequate oxygen (Timmins & Clark, 2015). Thus, variability is one of the most important characteristics of the FHR. Variability is described in four categories as follows: • fluctuation range undetectable • fluctuation range observed at 25 bpm Absent or minimal variability typically is caused by fetal acidemia secondary to uteroplacental insufficiency, cord compression, a preterm fetus, maternal hypotension, uterine hyperstimulation, abruptio placenta, or a fetal dysrhythmia. Interventions to improve uteroplacental blood flow and perfusion through the umbilical cord include lateral positioning of the mother, increasing the IV fluid rate to improve maternal circulation, administering oxygen at 8 to 10 L/min by mask, considering internal fetal monitoring, documenting findings, and reporting to the health care provider. Preparation for a surgical birth may be necessary if no changes occur after attempting the interventions. Moderate viability indicates that the autonomic and central nervous systems (CNSs) of the fetus are well developed and well oxygenated. It is considered a good sign of fetal well-being and correlates with the absence of significant metabolic acidosis (Fig. 14.7). Marked variability occurs when there are more than 25 beats of fluctuation in the FHR baseline. Causes of this include cord prolapse or compression, maternal hypotension, uterine hyperstimulation, and abruptio placenta. Interventions include determining the cause if possible, lateral positioning, increasing intravenous fluid rate, administering oxygen at 8 to 10 L/min by mask, discontinuing oxytocin infusion, observing for changes in tracing, considering

internal fetal monitoring, communicating an abnormal pattern to the health care provider, and preparing for a surgical birth if no change in pattern is noted (Freeman, 2015). FHR variability is an important clinical indicator that is predictive of fetal acid–base balance and cerebral tissue perfusion. It is influenced by fetal oxygenation status, cardiac output, and drug effects (King et al., 2015). As the CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears. Loss of variability may be associated with a poor outcome.

Take Note! External electronic fetal monitoring cannot assess variability accurately. Therefore, if external monitoring shows a baseline that is smoothing out, use of an internal spiral electrode should be considered to gain a more accurate picture of the fetal health status.

FIGURE 14.7 Examples of fetal monitoring strips. A. Long-term variability (average or moderate). B.

Minimal variability. C. Moderate variability. D. Marked variability.

PERIODIC BASELINE CHANGES Periodic baseline changes are temporary, recurrent changes made in response to a stimulus such as a contraction. The FHR can demonstrate patterns of acceleration or deceleration in response to most stimuli. Fetal accelerations are transitory abrupt increases in the FHR above the baseline that last 15 seconds, but less than 2 minutes (NICHD, 2015). They are generally considered reassuring and require no interventions. Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing. Concept Mastery Alert Responding to Fetal Heart Rate Distress During Labor During possible fetal distress that involves lack of variability, late decelerations, and fetal tachycardia, simply changing the woman’s position is inadequate. The nurse should notify the healthcare provider immediately regarding the situation.

FIGURE 14.8 Decelerations. A. Early. B. Variable. C. Late.

A deceleration is a transient fall in FHR caused by stimulation of the parasympathetic nervous system. Decelerations are described by their shape and association to a uterine contraction. They are classified as early, late, and variable only (Fig. 14.8). Early decelerations are visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. Typically, the onset, nadir, and recovery of the deceleration occur at the same time as the onset, peak, and recovery of the contraction. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Early decelerations are not indicative of fetal distress and do not require intervention. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists (Martin, Fanaroff, & Walsh, 2014).

Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia. Recurrent or intermittent late decelerations are always category II (indeterminate) or category III (abnormal) regardless of depth of deceleration. Acute episodes with moderate variability are more likely to be correctable, whereas chronic episodes with loss of variability are less likely to be correctable (Sholapurkar, 2015). Box 14.1 highlights interventions for category III decelerations. Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns (Cahill & Spain, 2015). Variable decelerations usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable (Ugwumadu, 2015). Variable decelerations are associated with cord compression. However, they are classified either as category II or III depending on the accompanying change in baseline variability (ICSI, 2015a). The pattern of variable deceleration consistently related to the contractions with a slow return to FHR baseline warrants further monitoring and evaluation.

BOX 14.1 INTERVENTIONS FOR CATEGORY III PATTERNS • Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. • Discontinue oxytocin or other uterotonic agent as dictated by the facility’s protocol, if it is being administered. • Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. • Administer oxygen via nonrebreather face mask to increase fetal oxygenation. • Increase the intravenous fluid rate to improve intravascular volume and correct maternal hypotension. • Assess the client for any underlying contributing causes. • Provide reassurance that interventions are to effect pattern change. • Modify pushing in the second stage of labor to improve fetal oxygenation. • Document any and all interventions and any changes in FHR patterns. • Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes. Adapted from American College of Obstetricians and Gynecologists [ACOG]. (2014). Safe prevention of the primary cesarean delivery. Obstetric Care Consensus 1, Obstetrics & Gynecology, 123, 693–711; Freeman, R. K. (2015). Intrapartum fetal heart rate monitoring. Protocols for high-risk pregnancies: An evidence-based approach (pp. 418–422, 6th ed.). John Wiley & Sons; and Cahill, A. G., & Spain, J. (2015). Intrapartum fetal monitoring. Clinical Obstetrics and Gynecology, 58(2), 263–268.

Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes, but less than 10 minutes (NICHD, 2015). The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, maternal seizures,

regional anesthesia, or uterine rupture (ACOG & SMFM 2014). Prolonged decelerations can be remedied by identifying the underlying cause and correcting it. A sinusoidal pattern is described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for >20 minutes. It is attributed to a derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a Category III pattern, and to correct it a fetal intrauterine transfusion would be needed (Nageotte, 2015). Combinations of FHR patterns obtained by EFM during labor are not infrequent. Category II and III patterns are more significant if they are mixed, persist for long periods, or have frequent prolonged late decelerations, absent or minimal variability, bradycardia or tachycardia, and prolonged variable decelerations lower than 60 bpm. The likelihood of fetal compromise is increased if Category II and III patterns are associated with decreased baseline variability or abnormal contraction patterns (ICSI, 2015a).

Other Fetal Assessment Methods In situations suggesting the possibility of fetal compromise, such as Category II or Category III FHR patterns, further ancillary testing such as umbilical cord blood analysis and fetal scalp stimulation may be used to validate the FHR findings and assist in planning interventions.

Take Note! In recent years, the use of fetal scalp sampling has decreased, being replaced by techniques that yield similar information. It has been shown to have a poor positive predictive value for intrapartum hypoxia and recent systematic reviews have reported no evidence of benefit in reducing cesarean section rates (Chandraharan, 2014).

Umbilical Cord Blood Analysis Neonatal and childhood mortality and morbidity, including cerebral palsy, are often attributed to fetal acidosis, as defined by a low cord pH at birth. Umbilical cord blood acid–base analysis drawn at birth provides an objective method of evaluating a newborn’s condition, identifying the presence of intrapartum hypoxia and acidemia. This test is considered a good indicator of fetal oxygenation and acid–base condition at birth (Martin, Fanaroff, & Walsh, 2014). The normal mean pH value range is 7.2 to 7.3. The pH values are useful for planning interventions for the newborn born with low 5-minute Apgar scores, severe FGR, Category II and III patterns during labor, umbilical cord prolapse, uterine rupture, maternal fever, placental abruption, meconium-stained amniotic fluid, and post-term births (Gujral & Nayar, 2015). The interventions needed for the compromised newborn might include providing an optimal extrauterine environment, fluids, oxygen, medications, and other treatments.

Fetal Scalp Stimulation An indirect method used to evaluate fetal oxygenation and acid–base balance to identify fetal hypoxia is fetal scalp stimulation or vibroacoustic stimulation. If the fetus does not have adequate oxygen reserves, carbon dioxide builds up,

leading to acidemia and hypoxemia. These metabolic states are reflected in abnormal FHR patterns as well as fetal inactivity. Fetal stimulation is performed to promote fetal movement with the hope that FHR accelerations will accompany the movement. Fetal movement can be stimulated with a vibroacoustic stimulator (artificial larynx) applied to the woman’s lower abdomen and turned on for 3 to 5 seconds to produce sound and vibration or by placing a gloved finger on the fetal scalp and applying firm pressure. A well-oxygenated fetus will respond when stimulated (tactile or by noise) by moving in conjunction with an acceleration of 15 bpm above the baseline heart rate that lasts at least 15 seconds. This FHR acceleration reflects a pH of more than 7 and a fetus with an intact CNS. Fetal scalp stimulation is not done if the fetus is preterm, or if the woman has an intrauterine infection, a diagnosis of placenta previa (which could lead to hemorrhage), or a fever (which increases the risk of an ascending infection) (King et al., 2015). If no acceleratory response by the fetus is exhibited with either scalp stimulation or vibroacoustic stimulation, further evaluation of the fetus is warranted. Nurses play an essential role in the evaluation of maternal and fetal status during labor, continued surveillance, initiation of corrective measures when indicated, and reevaluation. A vital attribute of nursing surveillance is that it is a systematic process for assessment, intervention, and evaluation.

PROMOTING COMFORT AND PROVIDING PAIN MANAGEMENT DURING LABOR Pain during labor is a universal experience, although the intensity of the pain may vary. Labor pain is unique to every woman based on various contributing physiologic, emotional, social, and cultural factors. Although labor and childbirth are viewed as natural processes, both can produce significant pain and discomfort. The physical causes of pain during labor include cervical stretching, hypoxia of the uterine muscle due to a decrease in perfusion during contractions, pressure on the urethra, bladder, and rectum, and distention of the muscles of the pelvic floor (Leonard, 2015). Pain during labor is a physiological phenomenon. The etiology of pain during the first stage of labor is associated with ischemia of the uterus during contractions. In the second stage, pain is caused by the stretching of the vagina and perineum and compression of the pelvic structures. A woman’s pain perception can be influenced by her previous experiences with pain, fatigue, pain anticipation, genetics, positive or negative support system, health care provider’s presence and encouragement, labor and birth environment, cultural expectations, and level of emotional stress and anxiety. Pain perception during labor changes in intensity and nature as labor progresses, and this is associated with behavioral changes in the laboring woman (Liu, Fernando, & Mon, 2015). The techniques used to manage the pain of labor vary according to geography and culture. For example, some Appalachian women believe that placing a hatchet or knife under the bed of a laboring woman may help “cut the pain of childbirth,” and a woman from this background may wish to do so in the hospital setting (Bowers, 2015). Asian, Latino, and Orthodox Jewish women may request that their own mothers, not their husbands, attend their births; husbands do not actively participate in the birthing process. Cherokee, Hmong, and Japanese women will often remain quiet during labor and birth and not complain of pain because outwardly expressing pain is not appropriate in their cultures. Never interpret their quietness as freedom from pain. The concept of pain and pain expression during labor has different meanings for women of different cultures. Several points for the nurse to consider when caring for diverse cultural clients include using a qualified interpreter to communicate about pain as needed, offer and support culturally acceptable forms of pain relief, and assess for pain

frequently (Wojnar & Narruhn, 2016). Immigrating to a new country is a stressful process of readjustment and change. Effective verbal communication and understanding nonverbal social cues are invaluable when providing care to diverse cultures. Culturally diverse childbearing families present to the labor and birth suites with the same needs and desires of all families. Give them the same respect and sense of welcome shown to all families. Make sure they have a high-quality birth experience: uphold their religious, ethnic, and cultural values and integrate them into care. Today, women have many safe nonpharmacologic and pharmacologic choices for the management of pain during labor and birth, which may be used separately or in combination with one another. Pharmacologic approaches are directed at eliminating the physical sensation of labor pain, whereas nonpharmacologic approaches are largely directed at prevention of suffering. Nurses are in an ideal position to provide childbearing women with balanced, clear, concise information about effective nonpharmacologic and pharmacologic measures to relieve pain. Pain management standards issued by the Joint Commission mandate that pain be assessed in all clients admitted to a health care facility. Attention to the pain that occurs during labor and childbirth should be a priority of care for all nurses (Jones et al., 2015). A pain assessment tool named the Coping with Labor Algorithm uses the FOCUS format “Plan, Do, Check, and Act” cycle in laboring women. This tool provides a mechanism for pain documentation and links it to nursing care interventions (Roberts et al., 2010). Thus, it is important for nurses to be knowledgeable about the most recent scientific research on labor pain relief modalities, to make sure that accurate and unbiased information about effective pain relief measures is available to laboring women, to be sure that the woman determines what is an acceptable labor pain level for her, and to allow the woman the choice of pain relief method.

Nonpharmacologic Measures Nonpharmacologic measures may include continuous labor support, hydrotherapy, hypnosis, ambulation and maternal position changes, transcutaneous electrical nerve stimulation (TENS), acupuncture and acupressure, attention focusing and imagery, therapeutic touch and massage, breathing techniques, and effleurage. Most of these methods are based on the gate control theory of pain, which proposes that local physical stimulation can interfere with pain stimuli by closing a hypothetical gate in the spinal cord, thus blocking pain signals from reaching the brain (McGeary, Swanholm, & Gatchel, 2015). It has long been a standard of care for labor nurses to first provide or encourage a variety of nonpharmacologic measures before moving to the pharmacologic interventions. Nonpharmacologic measures are usually simple, safe, and inexpensive to use. Many of these measures are taught in childbirth classes, and women should be encouraged to try a variety of methods prior to the real labor. Many of the measures need to be practiced for best results and coordinated with the partner/coach. The nurse provides support and encouragement for the woman and her partner using nonpharmacologic methods. Although women cannot consciously direct the labor contractions, they can control how they respond to them, thereby enhancing their feelings of control. See Evidence-Based Practice 14.2 for more information.

Continuous Labor Support Continuous labor support involves offering a sustained presence to the laboring woman by providing emotional support, comfort measures, advocacy, information and advice, and support for the partner. It is a non-pharmacologic, evidence-based strategy associated with reduced cesarean rates (Jackson & Gregory, 2015). A woman’s family, a midwife, a nurse, a doula, or anyone else close to the woman can provide this continuous presence. A support person can assist the woman to ambulate, reposition herself, and use breathing techniques. A support person can also aid with the use of acupressure, massage, music therapy, or therapeutic touch. During the natural course of childbirth, a laboring woman’s functional ability is limited secondary to pain, and she often has trouble making decisions. The support person can help make them based on his or her

knowledge of the woman’s birth plan and personal wishes. Research has validated the value of continuous labor support versus intermittent support in terms of fewer operative deliveries, cesarean births, and requests for pain medication. Continuous labor support has shown to have beneficial effects on the mother and the newborn primarily due to the reduction in anxiety during the laboring experience. Most women expressed greater satisfaction with their childbirth experience (Iravani et al., 2015).

EVIDENCE-BASED PRACTICE 14.2 EFFECTIVENESS OF AROMATHERAPY AND BIOFEEDBACK IN PROMOTION OF LABOR OUTCOME DURING CHILDBIRTH AMONG PRIMIGRAVIDAS

STUDY Labor pain is described as the most severe form of pain that every woman may experience during their lifetime. When considering labor analgesia, one is faced with a number of choices each with different advantages and disadvantages depending on the woman’s expectations and preferences. Many women would like to avoid taking medications or invasive methods for pain management because of the potential negative impact on their fetus during labor. Severe pain triggers a stress response which may lead to harmful effects on both mother and fetus. The purpose of this study was to evaluate the effect of aromatherapy (essential oils from plants are massaged in the skin and inhaled) and biofeedback (mother was asked to experience both the fetal heart sound and variation in contractions and consciously regulate them) in promotion of labor outcome during childbirth.

Findings Six hundred nulliparous women were selected randomly and assigned to an Aromatherapy group (n = 200), a biofeedback group (n = 200), or a control group (n = 200). The researchers rated pain by using a visual pain analog scale during their labors. Sixty nine percent of cases in the aromatherapy group expressed it was helpful, provided pain relief and emotional well-being during their labors. Biofeedback was also effective in reducing pain and duration of labor during childbirth compared with the control group.

Nursing Implications The results of this study indicated that the use of Aromatherapy and Biofeedback, as non-pharmacologic methods were both effective methods of reducing pain perception and duration of labor among women during labor. As a non-pharmacologic nursing intervention, these are easy to administer, cost effective, harmless and appealing to the mother without any apparent maternal or neonatal adverse effects. Adopted from Janula, R., & Mahipal, S. (2015). Effectiveness of aromatherapy and biofeedback in promotion of labor outcome during childbirth among primigravidas. Health Science Journal, 9(1), 1–5.

Take Note! The human presence is of immeasurable value to make the laboring woman feel secure.

Hydrotherapy Hydrotherapy is a nonpharmacologic measure that may involve showering or soaking in a regular tub or whirlpool bath. When showering is the selected method of hydrotherapy, the woman stands or sits in a shower chair in a warm shower and allows the water to gently glide over her abdomen and back. If a tub or whirlpool is chosen, the woman immerses herself in warm water for relaxation and relief of discomfort. When the woman enters the warm water, the warmth and buoyancy help to release muscle tension and can impart a sense of well-being (Taghavi, Barband, & Khaki, 2015). Warm water provides soothing stimulation of nerves in the skin, promoting vasodilation, reversal of sympathetic nervous response, and a reduction in catecholamines (Dalal, 2015). Contractions are usually less painful in warm water because the warmth and buoyancy of the water have a relaxing effect. Recent research findings reported that women who used hydrotherapy had significantly reduced surgical birth rates, a shorter second stage of labor, reduced analgesic requirements, and a lower incidence of perineal trauma (Taghavi, Barband, & Khaki, 2015). The research concluded that

hydrotherapy during labor significantly aids the labor process, minimizes the use of analgesic medications, offers fast- and short-acting pain and anxiety relief, and should he considered as a safe and effective birthing aid (Taghavi, Barband, & Khaki, 2015). A wide range of hydrotherapy options are available, from ordinary bathtubs to whirlpool baths and showers, combined with low lighting and music. Many hospitals provide showers and whirlpool baths for laboring women for pain relief. However, hydrotherapy is more commonly practiced in birthing centers managed by midwives. The recommendation for initiating hydrotherapy is that the woman be in active labor (more than 5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. The woman’s membranes can be intact or ruptured. Women are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temperature should not exceed body temperature. Hydrotherapy is an effective pain management option for many women. Women who are experiencing a healthy pregnancy can be offered this option. The potential risks associated with hydrotherapy including hyperthermia, hypothermia, changes in maternal heart rate, fetal tachycardia, and unplanned underwater birth. The benefits include reducing pain, relieving anxiety, and promoting a sense of control during labor (Nutter, 2016).

Ambulation and Position Changes Ambulation and position changes during labor are another extremely useful comfort measure. Historically, women adopted a variety of positions during labor, rarely using the recumbent position until during the first half of the twentieth century. The medical profession has favored recumbent positions during labor, but without evidence to demonstrate their appropriateness. A recent Cochrane database systematic review reported there is evidence that walking and upright positions in the first stage of labor reduce the length of labor and do not seem to be associated with increased intervention or negative effects on mothers’ and babies’ well-being. In an upright posture, gravity directs the weight of the fetus and amniotic fluid downwards, successively dilating the cervix and the birth canal. Uterine contractions have been shown to be better spaced, stronger and more efficient in dilating the cervix when the mother is in an upright position than when she is supine (Cox & King, 2015). Women should be encouraged to take up whatever position they find most comfortable in the first

stage of labor (Cheng & Caughey, 2015a). Changing position frequently (every 30 minutes or so)—sitting, walking, kneeling, standing, lying down, getting on hands and knees, and using a birthing ball—helps relieve pain (Fig. 14.9). Position changes also may help to speed labor by adding the benefits of gravity and changing the shape of the pelvis. Research has found that the position that the woman assumes and the frequency of position changes have a profound effect on uterine activity and efficiency. Allowing the woman to obtain a position of comfort frequently facilitates a favorable fetal rotation by altering the alignment of the presenting part with the pelvis. As the mother continues to change position based on comfort, the optimal presentation is afforded (King et al., 2015). Supine positions should be avoided, since they may interfere with labor progress and can cause compression of the vena cava and decrease blood return to the heart.

FIGURE 14.9 Various positions for use during labor. A. Ambulation. B. Leaning forward. C. Sitting in a chair. D. Using a birthing ball.

FIGURE 14.10 Nurse massaging the client’s back during a contraction while she ambulates during labor.

Swaying from side to side, rocking, or other rhythmic movements may also be comforting. If labor is progressing slowly, ambulating may speed it up again. Upright positions such as walking, kneeling forward, or doing the lunge on the birthing ball give most women a greater sense of control and active movement than just lying down. Table 14.2 highlights some of the more common positions that can be used during labor and birth.

Acupuncture and Acupressure Acupuncture and acupressure can be used to relieve pain during labor. Although controlled research studies of these methods are limited, there is adequate evidence that both are useful in relieving pain associated with labor and birth. However, both methods require a trained, certified clinician, and such a person is not available in many birth facilities (Halpern & Garg, 2015). Acupuncture involves stimulating key trigger points with needles. This form of Chinese medicine has been practiced for approximately 3,000 years. Classical Chinese teaching holds that throughout the body there are meridians or channels of energy (qi) that when in balance regulate body functions. Pain reflects an

imbalance or obstruction of the flow of energy. The purpose of acupuncture is to restore thus diminishing pain (Adams et al., 2015). Stimulating the trigger points causes the release of endorphins, reducing the perception of pain. Acupressure involves the application of a firm finger or massage used in acupuncture to reduce the pain sensation. The amount of pressure is important. The intensity of the pressure is determined by the needs of the woman. Holding and squeezing the hand of a woman in labor may trigger the point most commonly used for both techniques. Some acupressure points are found along the spine, neck, shoulder, toes, and soles of the feet. Pressure along the side of the spine can help relieve back pain during labor (Fig. 14.10) (Mollart, Adam, & Foureur, 2015). A Cochrane collaboration review found that acupuncture may indeed reduce labor pain, increasing satisfaction with pain management and reduced use of pharmacologic management. However, there is a need for further research (Simkin & Klein, 2015).

Application of Heat and Cold Superficial applications of heat and/or cold, in various forms, are popular with laboring women. They are easy to use, inexpensive, require no prior practice, and have minimal negative side effects when used properly. Heat is typically applied to the woman’s back, lower abdomen, groin, and/or perineum. Heat sources include a hot water bottle, heated rice-filled sock, warm compress (washcloth soaked in warm water and wrung out), electric heating pad, warm blanket, and warm bath or shower. In addition to being used for pain relief, heat is used to relieve chills or trembling, decrease joint stiffness, reduce muscle spasm, and increase connective tissue extensibility (Liu, Fernando, & Mon, 2015). Cold therapy, or cryotherapy, is usually applied on the woman’s back, chest, and/or face during labor. Forms of cold include a bag or surgical glove filled with ice, a frozen gel pack, camper’s “ice,” a hollow, plastic rolling pin or bottle filled with ice, a washcloth dipped in cold water, soda cans chilled in ice, and even a frozen bag of vegetables. “Instant” cold packs, often available in hospitals, usually are not cold enough to effectively relieve labor pain. Women who feel cold usually need to feel warm before they can comfortably tolerate using a cold pack. Chilled soda cans and rolling pins filled with ice give the added benefit of mechanical pressure when rolled on the low back. Cold has the additional effects of relieving muscle spasms and reducing inflammation and

edema (Tharpe, Farley, & Jordan, 2016). TABLE 14.2 Common Positions for use During Labor and Birth

To date, no randomized controlled studies have evaluated the use of heat and cold, so further study is needed to determine if either approach is efficacious. With appropriate safety precautions, heat and cold offer comfort and relief, and

their use should be dictated by the desires and responses of the laboring woman.

Attention Focusing and Imagery Attention focusing and imagery use many of the senses and the mind to focus on stimuli. The woman can focus on tactile stimuli such as touch, massage, or stroking. She may focus on auditory stimuli such as music, humming, or verbal encouragement. Visual stimuli might be any object in the room, or the woman can imagine the beach, a mountaintop, a happy memory, or even the contractions of the uterine muscle pulling the cervix open and the fetus pressing downward to open the cervix. Some women focus on a particular mental activity such as a song, a chant, counting backwards, or a Bible verse. Breathing, relaxation, positive thinking, and positive visualization work well for mothers in labor. The use of these techniques keeps the sensory input perceived during the contraction from reaching the pain center in the cortex of the brain (Capogna, 2015a).

Effleurage and Massage Effleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions. It is used as a relaxation and distraction technique from discomfort. External fetal monitor belts may interfere with the ability to accomplish this. Effleurage and massage use the sense of touch to promote relaxation and pain relief. Massage works as a form of pain relief by increasing the production of endorphins in the body. Endorphins reduce the transmission of signals between nerve cells and thus lower the perception of pain. Because touch receptors go to the brain faster than pain receptors, massage—anywhere on the body—can block the pain message to the brain. In addition, light touch has been found to release endorphins and induce a relaxed state. In addition, touching and massage distract the woman from discomfort. Massage involves manipulation of the body’s soft tissues. It is commonly used to help relax tense muscles and to soothe and calm the individual. Massage may help to relieve pain by assisting with relaxation, inhibiting sensory transmission in the pain pathways, or improving blood flow and oxygenation of tissues (Neetu & Panchal, 2015).

Breathing Techniques Conscious use of breath by the woman has the power to profoundly influence

her labor and how she engages with it. The first action anyone takes in any situation is a breath. The breath affects the lungs, immediately cueing the nervous system. The nervous system responds by sending messages, which impact our entire psycho-physiologic system. Messages sent from the nervous system affect us physically, emotionally, and mentally. If we alter how we breathe, we alter the constellation of messages and reactions in our entire mind– body experience (Cheng & Caughey, 2015a). Breathing techniques are effective in producing relaxation and pain relief through the use of distraction. If the woman is concentrating on slow-paced rhythmic breathing, she is not likely to fully focus on contraction pain. Breathing techniques are often taught in childbirth education classes (see Chapter 12 for additional information). Controlled breathing helps reduce the pain experienced by using stimulus– response conditioning. The woman selects a focal point within her environment to stare at during the first sign of a contraction. This focus creates a visual stimulus that goes directly to her brain. The woman takes a deep cleansing breath, which is followed by rhythmic breathing. Verbal commands from her partner supply an ongoing auditory stimulus to her brain. Benefits of practicing patterned breathing include: breathing • becomes an automatic response to pain. • increases relaxation and can be used for deal with life’s everyday stresses. • is calming during labor. • provides a sense of well-being and a measure of control. • brings purpose to each contraction, making them more productive. • provides more oxygen for the mother and fetus (American Pregnancy Association, 2015). Many couples learn patterned-paced breathing during their childbirth education classes. Three levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction. In the first pattern, also known as slow-paced breathing, the woman inhales slowly through her nose and exhales through pursed lips. The breathing rate is typically 6 to 9 bpm. In the second pattern, the woman inhales and exhales through her mouth at a rate of four breaths every 5 seconds. The rate can be accelerated to two breaths per second to assist her to relax. The third pattern is similar to the second pattern except that the breathing is punctuated every few breaths by a forceful exhalation through

pursed lips. All breaths are kept equal and rhythmic and can increase as contractions increase in intensity (Lindholm & Hildingsson, 2015). Many childbirth educators do not recommend specific breathing techniques or try to teach parents to breathe the “right” way during labor and birth. Couples are encouraged to find breathing styles that enhance their relaxation and use them. There are numerous benefits to controlled and rhythmic breathing in childbirth (outlined previously), and many women choose these techniques to manage their discomfort during labor.

Pharmacologic Measures With varying degrees of success, generations of women have sought ways to relieve the pain of childbirth. Pharmacologic pain relief during labor includes systemic analgesia and regional or local anesthesia. Women have seen dramatic changes in pharmacologic pain management options over the years. Methods have evolved from biting down on a stick to control their pain, experiencing ’twilight sleep’ during their labors and not remembering what happened, to a more complex pharmacologic approach such as epidural/intrathecal analgesia. Systemic analgesia and regional analgesia/anesthesia have become less common, while newer neuraxial analgesia/anesthesia techniques involving minimal motor blockade have become more popular. Neuraxial analgesia/anesthesia is the administration of analgesic (opioids) or anesthetic (capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain. Low-dose and ultra-lowdose epidural analgesia, spinal analgesia, and combined spinal–epidural analgesia have replaced the traditional epidural for labor. Neuraxial analgesia does not interfere with the progress or outcome of labor. There is no need to withhold neuraxial analgesia until the active stage of labor (Grant et al., 2015). This shift in pain management techniques allows a woman to be an active participant in labor.

Take Note! Regardless of which approach is used during labor, the woman has the right to choose the methods of pain control that will best suit her and meet her needs.

Systemic Analgesia Systemic analgesia involves the use of one or more drugs administered orally, intramuscularly, or intravenously; they become distributed throughout the body via the circulatory system. Depending on which administration method is used, the therapeutic effect of pain relief can occur within minutes and last for several hours. The most important complication associated with the use of this class of drugs is respiratory depression. Therefore, women given these drugs require

careful monitoring. Opioids given close to the time of birth can cause CNS depression in the newborn, necessitating the administration of naloxone (Narcan) to reverse the depressant effects of the opioids. Several drug categories may be used for systemic analgesia: • Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine, or fentanyl (Sublimaze) • Ataractics, such as hydroxyzine (Vistaril), promethazine (Phenergan), or prochlorperazine (Compazine) • Benzodiazepines, such as diazepam (Valium) or midazolam (Versed) Drug Guide 14.1 highlights some of the major drugs used for systemic analgesia. Systemic analgesics are typically administered parenterally, usually through an existing intravenous line. Nearly all medications given during labor cross the placenta and have a depressant effect on the fetus; therefore, it is important for the woman to receive the least amount of systemic medication that relieves her discomfort so that it does not cause any harm to the fetus (Cheng & Caughey, 2015a). Historically opioids have been administered by nurses, but in the past decade there has been increasing use of client-controlled intravenous analgesia (patient-controlled analgesia). With this system, the woman is given a button connected to a computerized pump on the intravenous line. When the woman desires analgesia, she presses the button and the pump delivers a preset amount of medication. This system provides the woman with a sense of control over her own pain management and active participation in the childbirth process.

DRUG GUIDE 14.1 Common Agents Used for Systemic Analgesia

OPIOIDS Opioids are morphine-like medications that are most effective for the relief of moderate to severe pain. Opioids typically are administered intravenously. All opioids are lipophilic and cross the placental barrier, but do not affect labor progress in the active phase. Opioids are associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding (King et al., 2015). Opioids decrease the transmission of pain impulses by binding to receptor site pathways that transmit the pain signals to the brain. The effect is increased tolerance to pain and respiratory depression related to a decrease in sensitivity to

carbon dioxide (Skidmore-Roth, 2015). All opioids are considered good analgesics. However, respiratory depression can occur in the mother and fetus depending on the dose given. They may also cause a decrease in FHR variability identified on the fetal monitor strip. This FHR pattern change is usually transient. Other systemic side effects include nausea, vomiting, pruritus, delayed gastric emptying, drowsiness, hypoventilation, and newborn depression. To reduce the incidence of newborn depression, birth should occur within 1 hour or after 4 hours of administration to prevent the fetus from receiving the peak concentration (Cheng & Caughey, 2015a). A recent study reported that parenteral opioids provide some relief from pain in labor, but are associated with neonatal respiratory distress. Maternal satisfaction with opioid analgesia appeared moderate at best (Kerr, Taylor, & Evans, 2015). Opioid antagonists such as naloxone (Narcan) are given to reverse the effects of the CNS depression, including respiratory depression, caused by opioids. Opioid antagonists also are used to reverse the side effects of neuraxial opioids, such as pruritus, urinary retention, nausea, and vomiting, without significantly decreasing analgesia (Skidmore-Roth, 2015). Consult a current drug guide for more specifics on these drug categories. ANTIEMETICS The antiemetic group of medications is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. These adjunct drugs potentiate the effectiveness of the opioid so that a lesser dose can be given. They may also be used to increase sedation. Promethazine (Phenergan) can be given intravenously, but hydroxyzine (Vistaril) must be given by mouth or by intramuscular injection into a large muscle mass. Neither drug affects the progress of labor, but either may cause a decrease in FHR variability and possible newborn depression (Skidmore-Roth, 2015). Prochlorperazine (Compazine) is typically given intravenously or intramuscularly with morphine sulfate for sleep during a prolonged latent phase. It counteracts the nausea associated with opioids (King et al., 2015). BENZODIAZEPINES Benzodiazepines are used for minor tranquilizing and sedative effects. Diazepam (Valium) also is given intravenously to stop seizures resulting from eclampsia. It can be administered to calm a woman who is out of control, thereby enabling her

to relax enough so that she can participate effectively during her labor process rather than fighting against it. Lorazepam (Ativan) can also be used for its tranquilizing effect, but increased sedation is experienced with this medication (Skidmore-Roth, 2015). Midazolam (Versed), also given intravenously, produces good amnesia but no analgesia. It is most commonly used as an adjunct for anesthesia. Diazepam and midazolam cause CNS depression for both the woman and the newborn.

Inhaled Analgesics Nitrous oxide is known by most people as “laughing gas.” For labor pain, half nitrous oxide gas (50%) is mixed with half oxygen (50%) and breathed through a mask or mouthpiece. This has been recently introduced in the United States, but has been in widespread use in Europe and Canada for many years. Women have generally reported satisfaction with the use of nitrous oxide for pain relief in labor. An additional factor that may contribute to the decreased perception of pain is maternal control—it is self-administered. Self-administration is not only empowering for women, but it also acts as a safety mechanism because it is almost impossible to overdose when it is self-administered (Halpern & Garg, 2015). Potential side effects of N2O/O2 include nausea and vomiting, dizziness, and dysphoria, although these are rare. No FHR abnormalities have been attributed to its use (Badve & Vallejo, 2015).

Regional Analgesia/Anesthesia Regional analgesia/anesthesia provides pain relief without loss of consciousness. It involves the use of local anesthetic agents, with or without added opioids, to bring about pain relief or numbness through the drug’s effects on the spinal cord and nerve roots. Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord (Stocks & Griffiths, 2015). The routes for regional pain relief include epidural block, combined spinal– epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia. Local and pudendal routes are used during birth for episiotomies (surgical incision into the perineum to facilitate birth); epidural and intrathecal routes are used for pain relief during active labor and birth. The major advantage of regional pain management techniques is that the woman can participate in the birthing process and still have good pain control.

EPIDURAL ANALGESIA Women requesting epidural analgesia in labor will do so when they feel they need pain relief, and for some it might be quite early in their labor. Epidural analgesia for labor and birth involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. A small catheter is then passed through the epidural needle to provide continuous access to the epidural space for maintenance of analgesia throughout labor and birth (Fig. 14.11). Epidural analgesia does increase the duration of the second stage of labor and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration (Camorcia, 2015). Approximately 60% of laboring women in the United States receive an epidural for pain relief during labor, but one in eight women who have an epidural during labor still need to use other methods of pain relief In urban areas, many hospitals approach 90% use of epidurals (Capogna, 2015b). An epidural involves the injection of a drug into the epidural space, which is located outside the dura mater between the dura and the spinal canal. The epidural space is typically entered through the third and fourth lumbar vertebrae with a needle, and a catheter is threaded into the epidural space. An epidural can be used for both vaginal and cesarean births. It has evolved from a regional block producing total loss of sensation to analgesia with minimal blockade. The effectiveness of epidural analgesia depends on the technique and medications used. Theoretically, epidural local anesthetics could block all labor pain if used in large volumes and high concentrations. However, pain relief is balanced against other goals such as walking during the first stage of labor, pushing effectively in the second stage, and minimizing maternal and fetal side effects. An epidural is contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects cardiac disease, obesity, infections, and hypovolemia. It also is contraindicated for the woman who is receiving anticoagulation therapy. Complications include nausea and vomiting, hypotension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression. Effects on the fetus during labor include fetal distress secondary to maternal hypotension (Ibrahim et al., 2015). Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help to minimize hypotension.

FIGURE 14.11 Epidural catheter insertion. A. A needle is inserted into the epidural space. B. A catheter is threaded into the epidural space; the needle is then removed. The catheter allows medication to be administered intermittently or continuously to relieve pain during labor and childbirth.

The addition of opioids, such as fentanyl or morphine, to the local anesthetic helps decrease the amount of motor block obtained. Continuous infusion pumps can be used to administer the epidural analgesia, allowing the woman to be in control and administer a bolus dose on demand (Patkar et al., 2015). COMBINED SPINAL–EPIDURAL ANALGESIA Another epidural technique is combined spinal–epidural (CSE) analgesia. This technique involves inserting the epidural needle into the epidural space and subsequently inserting a small-gauge spinal needle through the epidural needle into the subarachnoid space. An opioid, without a local anesthetic, is injected into this space. The spinal needle is then removed and an epidural catheter is inserted for later use. CSE is advantageous because of its rapid onset of pain relief (within 3 to 5 minutes) that can last up to 3 hours. It also allows the woman’s motor function to remain active. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact. The CSE technique provides greater flexibility and reliability for labor than either spinal or epidural analgesia alone (Stocks & Griffiths, 2015). When compared with traditional epidural or spinal analgesia, which often keeps the

woman lying in bed, CSE allows her to ambulate (“walking epidural”). A recent Cochrane review contrasting the CSE analgesia approach with traditional and low-dose epidural analgesia in labor identified that CSE analgesia was associated with a greater incidence of pruritus, but a lower incidence of urinary retention and need for rescue analgesia, than epidural along. In addition, CSE analgesia had a faster onset of pain relief, and there were no differences in labor outcomes (Heesen et al., 2015). Ambulating during labor provides several benefits: it may help control pain better, shorten the first stage of labor, increase the intensity of the contractions, and decrease the possibility of an operative vaginal or cesarean birth. Although women can walk with CSE, they often choose not to because of sedation and fatigue. Often health care providers do not encourage or assist women to ambulate for fear of injury. Nurses need to evaluate for ambulation safety that includes no postural hypotension and normal leg strength by demonstrating a partial knee bend while standing; they also need to assist with ambulation at all times (Capogna, 2015b). Currently, anesthesiologists are performing walking epidurals using continuous infusion techniques as well as CSE and client-controlled epidural analgesia (Grant et al., 2015). Complications include maternal hypotension, intravascular injection, accidental intrathecal blockade, postdural puncture headache, pruitis, inadequate or failed block, maternal fever, and pruritus. Hypotension and associated FHR changes are managed with maternal positioning (semi-Fowler’s position), intravenous hydration, and supplemental oxygen (Ibrahim et al., 2015).

Consider This

When I was expecting my first child, I was determined to put my best foot forward and do everything right. I was an experienced OB nurse, and in my mind doing everything right was expected behavior. I was already 2 weeks past my calculated due date and I was becoming increasingly worried. That particular day I went to work with a backache but felt no contractions. I managed to finish my shift but felt completely wiped out. As I walked to my car outside the hospital, my water broke and I felt the warm fluid run down my legs. I went back inside to be admitted for this much-awaited event.

Although I had helped thousands of women go through their childbirth experience, I was now the one in the bed and not standing alongside it. My husband and I had practiced our breathing techniques to cope with the discomfort of labor, but this “discomfort” in my mind was more than I could tolerate. So despite my best intentions of doing everything right, within an hour I begged for a painkiller to ease the pain. While the medication took the edge off my pain, I still felt every contraction and truly now appreciate the meaning of the word “labor.” Although I wanted to use natural childbirth without any medication, I know that I was a full participant in my son’s birthing experience, and that is what “doing everything right” was for me! Thoughts: Doing what is right varies for each individual, and as nurses we need to support whatever that is. Having a positive outcome from the childbirth experience is the goal; the means it takes to achieve it is less important. How can nurses support women in making their personal choices to achieve a healthy outcome? Are any women “failures” if they ask for pain medication to tolerate labor? How can nurses help women overcome this stigma of being a “wimp”? PATIENT-CONTROLLED EPIDURAL ANALGESIA Patient-controlled epidural analgesia (PCEA) involves the use of an indwelling epidural catheter with an infusion of medication and a programmed pump that allows the woman to control the dosing. This method allows the woman to have a sense of control over her pain and reach her own individually acceptable analgesia level. When compared with traditional epidural analgesia, PCEA provides equivalent analgesia with lower anesthetic use, lower rates of supplementation, and higher client satisfaction (Van De Velde, 2015). With PCEA, the woman uses a handheld device connected to an analgesic agent that is attached to an epidural catheter. When she pushes the button, a bolus dose of agent is administered via the catheter to reduce her pain. This method allows her to manage her pain at will without having to ask a staff member to provide pain relief. Evidence supports the use of PCEA which appears to result in greater maternal satisfaction and lower overall medication use (Sng et al., 2015). LOCAL INFILTRATION Local infiltration involves the injection of a local anesthetic, such as lidocaine,

into the superficial perineal nerves to numb the perineal area. This technique is done by the physician or midwife just before performing an episiotomy or before suturing a laceration. Local infiltration does not alter the pain of uterine contractions, but it does numb the immediate area of the episiotomy or laceration. Local infiltration does not cause side effects for the woman or her newborn. PUDENDAL NERVE BLOCK A pudendal nerve block refers to the injection of a local anesthetic agent (e.g., bupivacaine, ropivacaine) into the pudendal nerves near each ischial spine. It provides pain relief in the lower vagina, vulva, and perineum (Fig. 14.12). A pudendal block is used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. It must be administered about 15 minutes before it would be needed to ensure its full effect. A transvaginal approach is generally used to inject an anesthetic agent at or near the pudendal nerve branch. Neither maternal nor fetal complications are common.

FIGURE 14.12 Pudendal nerve block.

SPINAL (INTRATHECAL) ANALGESIA/ANESTHESIA The spinal (intrathecal) pain management technique involves injection of an anesthetic “caine” agent, with or without opioids, into the subarachnoid space to provide pain relief during labor or cesarean birth. The subarachnoid space is a fluid-filled area located between the dura mater and the spinal cord. Spinal anesthesia is frequently used for elective and emergent cesarean births. The contraindications are similar to those for an epidural block. Adverse reactions for the woman include hypotension and spinal headache. The subarachnoid injection of opioids alone, a technique termed intrathecal narcotics, has been gaining popularity since it was introduced in the 1980s. A narcotic is injected into the subarachnoid space, providing rapid pain relief while still maintaining motor function and sensation (Sng, Kwok, & Sia, 2015). An intrathecal narcotic is given during the active phase (more than 5 cm of dilation) of labor. Compared with epidural blocks, intrathecal narcotics are easy to administer, require a smaller volume of medication, produce excellent muscular relaxation, provide rapid-onset pain relief, are less likely to cause newborn respiratory depression, and do not cause motor blockade (Badve & Vallejo, 2015). Although pain relief is rapid with this technique, it is limited by the narcotic’s duration of action, which may be only a few hours and not last through the labor. Additional pain measures may be needed to sustain pain management.

General Anesthesia General anesthesia is typically reserved for emergency cesarean births when there is not enough time to provide spinal or epidural anesthesia or if the woman has a contraindication to the use of regional anesthesia. It can be started quickly and causes a rapid loss of consciousness. General anesthesia can be administered by intravenous injection, inhalation of anesthetic agents, or both. Commonly, thiopental, a short-acting barbiturate, or propofol is given intravenously to produce unconsciousness. This is followed by administration of a muscle relaxant. After the woman is intubated, nitrous oxide and oxygen are administered. A volatile halogenated agent may also be administered to produce amnesia (Cheng & Caughey, 2015a). All anesthetic agents cross the placenta and affect the fetus. The primary

complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration. General anesthesia complications are usually due to maternal aspiration or the inability to intubate the woman. The incidence of these complications has decreased greatly as a result of improved techniques (Hawkins, 2015). Although the anesthesiologist or nurse anesthetist administers the various general anesthesia agents, the nurse needs to be knowledgeable about the pharmacologic aspects of the drugs used and must be aware of airway management. Ensure that the woman is not taking anything by mouth (NPO) and has a patent intravenous line. In addition, administer a nonparticulate (clear) oral antacid (e.g., Bicitra or sodium citrate) or a proton pump inhibitor (Protonix) as ordered to reduce gastric acidity. Assist with placement of a wedge under the woman’s right hip to displace the gravid uterus and prevent vena cava compression in the supine position. Once the newborn has been removed from the uterus, assist the perinatal team in providing supportive care.

NURSING CARE DURING LABOR AND BIRTH Childbirth, a physiologic process that is fundamental to all human existence, is one of the most significant cultural, psychological, spiritual, and behavioral events in a woman’s life. Although the act of giving birth is a universal phenomenon, it is a unique experience for each woman. Continuous evaluation and appropriate intervention for women during labor are essential to promoting a positive outcome for the family. The nurse’s role in childbirth is to ensure a safe environment for the mother and her newborn. Nurses begin evaluating the mother and fetus during the admission procedures at the health care agency and continue to do so throughout labor. It is critical to provide anticipatory guidance and explain each procedure (fetal monitoring, intravenous therapy, medications given and expected reactions) and what will happen next. This will prepare the woman for the upcoming physical and emotional challenges, thereby helping to reduce her anxiety. Acknowledging members of her support system (family or partner) helps allay their fears and concerns, thereby assisting them in carrying out their supportive role. Knowing how and when to evaluate a woman during the various stages of labor is essential for all labor and birth nurses to ensure a positive maternal experience and a healthy newborn. A major focus of care for the woman during labor and birth is assisting her with maintaining control over her pain, emotions, and actions while being an active participant. Nurses can help and support women to be actively involved in their childbirth experience by allowing time for discussion, offering companionship, listening to worries and concerns, paying attention to the woman’s emotional needs, and offering information to help her understand what is happening in each stage of labor.

Nursing Management During the First Stage of Labor Depending on how far advanced the woman’s labor is when she arrives at the facility; the nurse will determine assessment parameters of maternal-fetal status and plan care accordingly. The nurse will provide high-touch, low-tech supportive nursing care during the first stage of labor when admitting the woman and orienting her to the labor and birth suite. The nurse is usually the primary gatekeeper of observations, interventions, treatments, and often the management of labor in the inpatient perinatal setting. Nursing care during this stage will include taking an admission history (reviewing the prenatal record); checking the results of routine laboratory tests and any special tests such as chorionic villi sampling, amniocentesis, genetic studies, and biophysical profile done during pregnancy; asking the woman about her childbirth preparation (birth plan, classes taken, coping skills); and completing a physical assessment of the woman to establish baseline values for future comparison. Key nursing interventions include: • Identifying the estimated date of birth from the client and the prenatal chart • Validating the client’s prenatal history to determine fetal risk status • Determining fundal height to validate dates and fetal growth • Performing Leopold’s maneuvers to determine fetal position, lie, and presentation • Checking FHR • Performing a vaginal examination (as appropriate) to evaluate effacement and dilation progress • Instructing the client and her partner about monitoring techniques and equipment • Assessing fetal response and FHR to contractions and recovery time • Interpreting fetal monitoring strips • Checking FHR baseline for accelerations, variability, and decelerations • Repositioning the client to obtain an optimal FHR pattern • Recognizing FHR problems and initiating corrective measures • Checking amniotic fluid for meconium staining, odor, and amount

• Comforting client throughout testing period and labor • Documenting times of notification for team members if problems arise • Knowing appropriate interventions when abnormal FHR patterns present • Supporting the client’s decisions regarding intervention or avoidance of intervention • Assessing the client’s support system and coping status frequently In addition to these interventions to promote optimal outcomes for the mother and fetus, the nurse must document care accurately and in a timely fashion. Accurate and timely documentation helps to decrease professional liability exposure, minimize the risk of preventable injuries to women and infants during labor and birth, and preserve families (Simpson, 2015). Guidelines for recording care include documenting: • All care rendered, to prove that standards were met • Conversations with all providers, including notification times • Nursing interventions before and after notifying provider • Use of the chain of command and response at each level • All flow sheets and forms, to validate care given • All education given to client and response to it • Facts, not personal opinions • detailed descriptions of any adverse outcome • Initial nursing assessment, all encounters, and discharge plan • All telephone conversations (Callahan, 2016). This standard of documentation is needed to prevent or defend against litigation, which is prevalent in the childbirth arena.

Assessing the Woman Upon Admission The nurse usually first comes in contact with the woman either by phone or in person. The nurse should ascertain whether the woman is in true or false labor and whether she should be admitted or sent home. Upon admission to the labor and birth suite, the highest priorities include assessing FHR, assessing cervical dilation/effacement, and determining whether membranes have ruptured or are

intact. These assessment data will guide the critical thinking in planning care for the client. If the initial contact is by phone, establish a therapeutic relationship with the woman. Speaking in a calm caring tone facilitates this. Nurses providing a telephone triage service need to have sufficient clinical experience and have clear lines of responsibility to enable sound decision making. When completing a phone assessment, include questions about the following: • Estimated date of birth, to determine if term or preterm • Fetal movement (frequency in the past few days) • Other premonitory signs of labor experienced • Parity, gravida, and previous childbirth experiences • Time from start of labor to birth in previous labors • Characteristics of contractions, including frequency, duration, and intensity • Appearance of any vaginal bloody show • Membrane status (ruptured or intact) • Presence of supportive adult in household or if she is alone When speaking with the woman over the telephone, review the signs and symptoms that denote true versus false labor, and suggest various positions she can assume to provide comfort and increase placental perfusion. Also suggest walking, massage, and taking a warm shower to promote relaxation. Outline what foods and fluids are appropriate for oral intake in early labor. Throughout the phone call, listen to the woman’s concerns and answer any questions clearly. Reducing the risk of liability exposure and avoiding preventable injuries to mothers and fetuses during labor and birth can be accomplished by adhering to two basic tenets of clinical practice: (1) use applicable evidence and/or published standards and guidelines as the foundation of care, and (2) whenever a clinical choice is presented, choose client safety (Miller, 2014). With these two tenets in mind, advise the woman on the phone to contact her health care provider for further instructions or to come to the facility to be evaluated, since ruling out true labor and possible maternal-fetal complications cannot be done accurately over the phone. Additional nursing responsibilities associated with a phone assessment include: • Consulting the woman’s prenatal record for parity status, estimated date of birth, and untoward events

• Calling the health care provider to inform him or her of the woman’s status • Preparing for admission to the perinatal unit to ensure adequate staff assignment • Notifying the admissions office of a pending admission If the nurse’s first encounter with the woman is in person, an assessment is completed to determine whether she should be admitted to the perinatal unit or sent home until her labor advances. Recent research findings suggest that women admitted before active labor are approximately twice as likely to be augmented with oxytocin and give birth via cesarean when compared with women admitted in active labor (Neal et al., 2014). Nurses need to make careful assessment of labor progression prior to labor admission to decrease early admissions and to improve labor safety and birth outcomes. Entering a facility is often an intimidating and stressful event for women since it is an unfamiliar environment. Giving birth for the first time is a pivotal event in the lives of most women. Therefore, demonstrate respect when addressing the client; listen carefully and express interest and concern. Nurses must value and respect women and promote their self-worth and sense of control by allowing them to participate in making decisions. Allowing them a fair amount of autonomy in their childbirth decisions, supporting their personal worth, knowing them holistically, and using caring communication will increase client satisfaction (Ivory, 2014). An admission assessment includes maternal health history, physical assessment, fetal assessment, laboratory studies, and assessment of psychological status. Usually the facility has a form that can be used throughout labor and birth to document assessment findings (Fig. 14.13). MATERNAL HEALTH HISTORY AND CULTURAL ASSESSMENT A maternal health history should include typical biographical data such as the woman’s name and age and the name of the delivering health care provider. Other information that is collected includes reason for admission, such as labor, cesarean birth, or observation for a complication; the prenatal record data, including the estimated date of birth, a history of the current pregnancy, and the results of any laboratory and diagnostic tests, such as blood type, Rh status, and group B streptococcal status; past pregnancy and obstetric history; past health history and family history; prenatal education; list of medications; risk factors

such as diabetes, hypertension, and use of tobacco, alcohol, or illicit drugs; pain management plan; history of potential domestic violence; history of previous preterm births; allergies; time of last food ingestion; method chosen for infant feeding; name of birth attendant (MD or midwife)(s) and pediatrician. Ascertaining this information is important so that an individualized plan of care can be developed for the woman. If, for example, the woman’s due date is still 2 months away, it is important to establish this information so interventions can be initiated to arrest the labor immediately or notify the intensive perinatal team to be available. In addition, if the woman has diabetes, it is critical to monitor her glucose levels during labor, to prepare for a surgical birth if dystocia of labor occurs, and to alert the newborn nursery of potential hypoglycemia in the newborn after birth. By collecting important information about each woman they care for, nurses can help improve the outcomes for all concerned. Be sure to observe the woman’s emotions, support system, verbal interaction, cultural background and language spoken, body language and posture, perceptual acuity, and energy level. This psychosocial information provides cues about the woman’s emotional state, culture, and communication systems. For example, if the woman arrives at the labor and birth suite extremely anxious, alone, and unable to communicate in English, how can the nurse meet her needs and plan her care appropriately? It is only by assessing each woman physically and psychosocially that the nurse can make astute decisions regarding proper care. In this case, an interpreter would be needed to assist in the communication process between the staff and the woman to initiate proper care.

BOX 14.2 QUESTIONS FOR PROVIDING CULTURALLY COMPETENT CARE DURING LABOR AND BIRTH • Where were you born? How long have you lived in the United States? • What languages do you speak and read? • Who are your major support people? • What are your religious practices? • How do you view childbearing? • Are there any special precautions or restrictions that are important? • Is birth considered a private or a social experience? • How would you like to manage your labor discomfort? • Who will provide your labor support? Adapted from Bowers, P. (2015). Cultural perspectives in childbearing. Nursing Spectrum. Retrieved from http://ce.nurse.com/ce263-60/cultural-perspectives-in-childbearing; and Anderson, L. (2014). Cultural

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It is important to acknowledge and try to understand the cultural differences in women with cultural backgrounds different from that of the nurse. Attitudes toward childbirth are heavily influenced by the culture in which the woman has been raised. As a result, within every society, specific attitudes and values shape the woman’s childbearing behaviors. Be aware of what these are. When carrying out a cultural assessment during the admission process, ask questions (Box 14.2) to help plan culturally competent care during labor and birth. PHYSICAL EXAMINATION The physical examination typically includes a generalized assessment of the woman’s body systems, including hydration status, vital signs, auscultation of heart and lung sounds, and measurement of height and weight. The physical examination also includes the following assessments:

1. Pain level and coping behaviors demonstrated 2. Uterine activity, including contraction frequency, duration, and intensity 3. Fetal status, including heart rate, position, and station 4. Cervical dilation and degree of effacement 5. Status of membranes (intact or ruptured) 6. Assess vital signs: temperature, pulse, respirations & blood pressure 7. Perform Leopold’s maneuvers to determine fetal lie 8. Fundal height measurement 9. Ability to ambulate safely These assessment parameters form a baseline against which the nurse can compare all future values throughout labor. The findings should be similar to those of the woman’s prepregnancy and pregnancy findings, with the exception of her pulse rate, which might be elevated secondary to her anxious state with beginning labor.

FIGURE 14.13 Sample documentation form used for admission to the perinatal unit. (Used with permission. Briggs Corporation, 2001.)

LABORATORY STUDIES On admission, laboratory studies typically are done to establish a baseline. Although the exact tests may vary among facilities, they usually include a urinalysis via clean-catch urine specimen and complete blood count. Blood typing and Rh factor analysis may be necessary if the results of these are unknown or unavailable. In addition, if the following test results are not included in the maternal prenatal history, it may be necessary to perform them at this time. They include syphilis screening, hepatitis B (HbsAg) screening, group B streptococcus, human immune deficiency virus (HIV) testing (if woman gives consent), and possible drug screening if the history is positive. Group B streptococcus (GBS) is a gram-positive organism that colonizes in the female genital tract and rectum and is present in 10% to 30% of all healthy women (King et al., 2015). These women are asymptomatic carriers but can cause GBS disease of the newborn through vertical transmission during labor and horizontal transmission after birth. The mortality rate of infected newborns varies according to time of onset (early or late). Risk factors for GBS include maternal intrapartum fever, prolonged ruptured membranes (>12 to 18 hours), previous birth of an infected newborn, and GBS bacteriuria in the present pregnancy. The Centers for Disease Control and Prevention (CDC), ACOG and the American Academy of Pediatrics have guidelines that advised universal screening of pregnant women at 35 to 37 weeks’ gestation for GBS and intrapartum antibiotic therapy for GBS carriers. These new guidelines reaffirmed the major prevention strategy—universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture-positive and high-risk women. Also included are new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants (Centers for Disease Control and Prevention [CDC], 2014). Maternal infections associated with GBS include acute chorioamnionitis, endometritis, and urinary tract infection. Neonatal clinical manifestations include pneumonia and sepsis. Identified GBS carriers receive intravenous antibiotic prophylaxis (penicillin G

or ampicillin) at the onset of labor or ruptured membranes. The ACOG, CDC, AWHONN and the United States Preventive Services Task Force all recommend that all pregnant women be offered a screening test for HIV antibodies on their first prenatal visit, again during the third trimester if engaging in high-risk behaviors, and on admission to the labor and birth area. The CDC estimates that 50,000 individuals contract HIV in the United States each year, and 250,000 individuals have undiagnosed HIV infections (CDC, 2015). If her HIV status is not documented, the woman being admitted to the labor and birth suite should have rapid HIV testing done. To reduce perinatal transmission, women who are HIV-positive are given zidovudine (2 mg/kg intravenously over an hour, and then a maintenance infusion of 1 mg/kg per hour until birth) or a single 200-mg oral dose of nevirapine at the onset of labor; the newborn is given zidovudine orally (2 mg/kg body weight every 6 hours) and should be continued for 6 weeks (Verklan & Walden, 2014). To further reduce the risk of perinatal transmission, ACOG and the United States Public Health Service recommend that women who are infected with HIV and have plasma viral loads of more than 1,000 copies/mL be counseled regarding the benefits of elective cesarean birth. In the absence of any medical intervention, the rate of vertical transmission of HIV to the fetus can range from 15% to 45% (Ashimi et al., 2015). Additional interventions to reduce the transmission risk would include avoiding use of a scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy, encouraging formula feeding after birth, and avoiding invasive procedures such as forceps or vacuum-assisted devices. The nurse stresses the importance of all interventions and the goal to reduce transmission of HIV to the newborn.

Continuing Assessment During the First Stage of Labor After the admission assessment is complete and the woman and her support person have been orientated to the room, equipment, and procedures, assessment continues for changes that would indicate that labor is progressing as expected. Assess the woman’s knowledge, experience, and expectations of labor. Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labor unless the clinical situation dictates that vital signs be taken more frequently. During the active and transition phases, they are assessed every 30

minutes. The temperature is taken every 4 hours throughout the first stage of labor and every 2 hours after membranes have ruptured to detect an elevation indicating an ascending infection. Vaginal examinations are performed periodically to track labor progress. This assessment information is shared with the woman to reinforce that she is making progress toward the goal of birth. Uterine contractions are monitored for frequency, duration, and intensity every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 15 minutes during transition. Note the changes in the character of the contractions as labor progresses, and inform the woman of her progress. Continually determine the woman’s level of pain and her ability to cope and use relaxation techniques effectively. When the fetal membranes rupture, spontaneously or artificially, assess the FHR and check the amniotic fluid for color, odor, and amount. Assess the FHR intermittently or continuously via electronic monitoring. During the latent phase of labor, assess the FHR every 30 to 60 minutes; in the active phase, assess FHR at least every 15 to 30 minutes. Also, be sure to assess the FHR before ambulation, before any procedure, and before administering analgesia or anesthesia to the mother. Table 14.3 summarizes assessments for the first stage of labor. Remember Sheila from the chapter-opening scenario? What is the nurse’s role with Sheila in active labor? What additional comfort measures can the labor nurse offer Sheila?

Nursing Interventions Nursing interventions during the admission process should include: • Asking about the client’s expectations of the birthing process • Providing information about labor, birth, pain management options, and relaxation techniques • Presenting information about fetal monitoring equipment and the procedures needed • Monitoring FHR and identifying patterns that need further intervention • Monitoring the mother’s vital signs to obtain a baseline for later comparison

• Reassuring the client that her labor progress will be monitored closely and nursing care will focus on ensuring fetal and maternal well-being throughout As the woman progresses through the first stage of labor, nursing interventions include: • Encouraging the woman’s partner to participate • Keeping the woman and her partner up to date on the progress of the labor • Orienting the woman and her partner to the labor and birth unit and explaining all of the birthing procedures • Providing clear fluids (e.g., ice chips) as needed or requested • Maintaining the woman’s parenteral fluid intake at the prescribed rate if she has an IV • Initiating or encouraging comfort measures, such as backrubs, cool cloths to the forehead, frequent position changes, ambulation, showers, slow dancing, leaning over a birth ball, side-lying, or counterpressure on lower back (Teaching Guidelines 14.1) TABLE 14.3 SUMMARY OF ASSESSMENTS DURING THE FIRST STAGE OF LABOR

Teaching Guidelines 14.1

POSITIONING DURING THE FIRST STAGE OF LABOR • Walking with support from the partner (adds the force of gravity to contractions to promote fetal descent) • Slow-dancing position with the partner holding the woman (adds the force of gravity to contractions and promotes support from and active participation of your partner) • Side lying with pillows between the knees for comfort (offers a restful position and improves oxygen flow to the uterus) • Semi-sitting in bed or on a couch leaning against the partner (reduces back pain because fetus falls forward, away from the sacrum) • Sitting in a chair with one foot on the floor and one on the chair (changes pelvic shape) • Leaning forward by straddling a chair, a table, or a bed or kneeling over a

birth ball (reduces back pain, adds the force of gravity to promote descent; possible pain relief if partner can apply sacral pressure) • Encourage any position of comfort the woman choses to labor in and give birth. • Sitting in a rocking chair or on a birth ball and shifting weight back and forth (provides comfort because rocking motion is soothing; uses the force of gravity to help fetal descent) • Lunge by rocking weight back and forth with foot up on chair during contraction (uses force of gravity by being upright; enhances rotation of fetus through rocking) • Open knee–chest position (helps to relieve back discomfort) (Gizzo et al., 2014; Tharpe et al., 2016). • Encouraging the partner’s involvement with breathing techniques • Assisting the woman and her partner to focus on breathing techniques • Informing the woman that the discomfort will be intermittent and of limited duration; urging her to rest between contractions to preserve her strength; and encouraging her to use distracting activities to lessen the focus on contractions • Changing bed linens and gown as needed • Keeping the perineal area clean and dry • Supporting the woman’s decisions about pain management • Monitoring maternal vital signs frequently and reporting any abnormal values • Ensuring that the woman takes deep cleansing breaths before and after each contraction to enhance gas exchange and oxygen to the fetus • Educating the woman and her partner about the need for rest and helping them plan strategies to conserve strength • Monitoring FHR for baseline, accelerations, variability, and decelerations • Checking on bladder status and encouraging voiding at least every 2 hours to make room for birth • Repositioning the woman as needed to obtain optimal heart rate pattern • Communicating requests from the woman to appropriate personnel • Respecting the woman’s sense of privacy by covering her when appropriate

• Offering human presence by being present with the woman, not leaving her alone for long periods • Being patient with the natural labor pattern to allow time for change • Encouraging maternal movement throughout labor to increase the woman’s level of comfort • Dimming the lights in the room when pushing and request softened voices be used to maintain a calm and centered ambiance • Reporting any deviations from normal to the health care professional so that interventions can be initiated early to be effective (Green, 2016; Lucas et al., 2015; Nagtalon-Ramos, 2014). See Nursing Care Plan 14.1.

Nursing Management During the Second Stage of Labor Management of the second stage of labor often follows tradition-based routines rather than evidence-based practices. Current evidence for management of the second stage of labor supports the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice positions (Cox & King, 2015). To be able to help women through the second stage of labor requires the nurse to have a comprehensive understanding of physiology and be aware of the latest evidence-based research and apply it to practice (Green, 2016). Nursing care during the second stage of labor focuses on supporting the woman and her partner in making active decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing instruction and assistance, and using maternal positions that can enhance descent and reduce pain (King et al., 2015). Women in the past gave birth unaided by following their bodies signals to birth their babies, so the role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor, but empowering women to achieve a satisfying experience. The primary rationale for directing women to push is to shorten the second stage of labor. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early (Reed, 2015). Shortening the phase of active pushing and lengthening the early phase of passive descent can be achieved by encouraging the woman not to push until she has a strong desire to do so and until the descent and rotation of the fetal head are well advanced. Effective pushing can be achieved by assisting the woman to assume a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice (Cheng & Caughey, 2015b).

NURSING CARE PLAN 14.1 Overview of a Woman in the Active Phase of the First Stage of Labor Candice, a 23-year-old gravida 1, para 0 (G1,P0), is admitted to the labor and birth suite at 39 weeks’ gestation having contractions of moderate intensity every 5 to 6 minutes. A vaginal examination reveals that her cervix is 80% effaced and 5 cm dilated. The presenting part (vertex) is at 0 station and her membranes ruptured spontaneously 4 hours ago at home. She is admitted and an intravenous line is started for hydration and vascular access. An external fetal monitor is applied. FHR is 140 bpm and regular. Her partner is present at her bedside. Candice is now in the active phase of the first stage of labor, and her assessment findings are as follows: cervix dilated 7 cm, 80% effaced; moderate to strong contractions occurring regularly, every 3 to 5 minutes, lasting 45 to 60 seconds; at 0 station on pelvic examination; FHR auscultated loudest below umbilicus at 140 bpm; vaginal show—pink or bloody vaginal mucus; currently apprehensive, inwardly focused, with increased dependency; voicing concern about ability to cope with pain; limited ability to follow directions. NURSING DIAGNOSIS: Anxiety related to labor and birth process and fear of the unknown related to client’s first experience Outcome Identification and Evaluation The client will remain calm and in control as evidenced by ability to make decisions and use positive coping strategies. Interventions: Promoting Positive Coping Strategies • Provide instruction regarding the labor process to allay anxiety. • Orient the woman to the physical environment and equipment as necessary to keep her informed of events. • Encourage verbalization of feelings and concerns to reduce anxiety. • Listen attentively to woman and partner to demonstrate interest and concern. • Inform woman and partner of standard procedures/processes to ensure adequate understanding of events and procedures. • Frequently update woman of progress and labor status to provide positive

reinforcement for actions. • Reinforce relaxation techniques and provide instruction if needed to aid in coping. • Encourage participation of the partner in the coaching role; role-model to facilitate partner participation in labor process to provide support and encouragement to the client. • Provide a presence and remain with the client as much as possible to provide comfort and support. NURSING DIAGNOSIS: Acute pain related to uterine contractions and stretching of the cervix and birth canal Outcome Identification and Evaluation The client will maintain a tolerable level of pain and discomfort as evidenced by statements of pain relief, pain rating of 2 or less on pain rating scale, and absence of adverse effects in client and fetus from analgesia or anesthesia. Interventions: Providing Pain Relief • Monitor vital signs, observe for signs of pain, and have client rate pain on a scale of 0 to 10 to provide baseline for comparison. • Encourage client to void every 1 to 2 hours to decrease pressure from a full bladder. • Assist woman to change positions frequently to increase comfort and promote labor progress. • Encourage use of distraction to reduce focus on contraction pain. • Suggest pelvic rocking, massage, or back counter pressure to reduce pain. • Assist with use of relaxation and breathing techniques to promote relaxation. • Use touch appropriately (backrub) when desired by the woman to promote comfort. • Integrate use of nonpharmacologic measures for pain relief, such as warm water, birthing ball, or other techniques to facilitate pain relief. • Administer pharmacologic agents as ordered when requested to control pain. • Provide reassurance and encouragement between contractions to foster selfesteem and continued participation in labor process.

NURSING DIAGNOSIS: Risk of infection related to multiple vaginal examinations following rupture of membranes and tissue trauma Outcome Identification and Evaluation The client will remain free of infection as evidenced by the absence of signs and symptoms of infection, vital signs and FHR within acceptable parameters, lab test results within normal limits, and clear amniotic fluid without odor. Interventions: Preventing Infection • Monitor vital signs (every 2 hours after rupture of membranes [ROM]) and FHR frequently as per protocol to allow for early detection of problems; report fetal tachycardia (early sign of maternal infection) to ensure prompt treatment. • Provide frequent perineal care and pad changes to maintain good perineal hygiene. • Change linens and woman’s gown as needed to maintain cleanliness. • Ensure that vaginal examinations are performed only when needed to prevent introducing pathogens into the vaginal vault. • Monitor lab test results such as white blood cell count to assess for elevations indicating infection. • Use aseptic technique for all invasive procedures to prevent infection transmission. • Carry out good handwashing techniques before and after procedures and use standard precautions as appropriate to minimize risk of infection transmission. • Document amniotic fluid characteristics—color, odor—to establish baseline for comparison. Perineal lacerations or tears can occur during the second stage when the fetal head emerges through the vaginal introitus. The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a seconddegree laceration extends through the muscles of the perineal body; a thirddegree laceration continues through the anal sphincter muscle; and a fourthdegree laceration also involves the anterior rectal wall. Special attention needs to be paid to third- and fourth-degree lacerations to prevent fecal incontinence.

Risks for third- or fourth-degree lacerations included nulliparity, being Asian or Pacific Islander, increased birth weight of newborn, operative vaginal birth, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations (Sides et al., 2015). The primary care provider should repair any lacerations during the third stage of labor. An episiotomy is an incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor. Alternative measures such as warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent cutting it. Certified nurse midwives can cut and repair episiotomies, but they frequently use alternative measures if possible.

Take Note! Restrictive use of episiotomy has been recommended by ACOG given the risks of the procedure and unclear benefits of routine use (Friedman et al., 2015). The midline episiotomy has been the most commonly used one in the United States because it can be easily repaired and causes the least amount of pain. The application of warmed compresses and/or intrapartum perineal massage is associated with a decrease in trauma to the perineal area and reduced the need for an episiotomy (Green, 2016). Routine episiotomy has declined since liberal usage has been discouraged by ACOG, except to avoid several maternal lacerations or to expedite difficult births Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds with a sharp increase in cesarean births, which may indicate that health care providers are favoring cesarean births for difficult births (Faisal-Cury et al., 2015). Figure 14.14 shows episiotomy locations.

Continuous Assessment During the Second Stage of Labor Assessment is continuous during the second stage of labor. Hospital policies dictate the specific type and timing of assessments, as well as the way in which they are documented. Assessment involves identifying the signs typical of the second stage of labor, including:

• Increase in apprehension or irritability • Spontaneous rupture of membranes • Sudden appearance of sweat on upper lip • Increase in blood-tinged show • Low grunting sounds from the woman • Complaints of rectal and perineal pressure • Beginning of involuntary bearing-down efforts Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the copying status of the woman and her partner (Table 14.4). Assessment also focuses on determining the progress of labor. Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn’s head during and between bearing-down efforts, and crowning (fetal head is visible at vaginal opening; Fig. 14.15). A vaginal examination is completed to determine if it is appropriate for the woman to push. Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so.

Nursing Interventions Nursing interventions during this stage focus on motivating the woman, assisting with positioning and encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress. If the woman is pushing without progress, suggest that she keep her eyes open during the contractions and look toward where the newborn is coming out. Changing positions frequently will also help in making progress. Positioning a mirror so the woman can visualize the birthing process and how successful her pushing efforts are can help motivate her.

FIGURE 14.14 Location of an episiotomy. A. Midline episiotomy. B. Right and left mediolateral episiotomies.

TABLE 14.4 Summary of Assessments During the Second, Third, and Fourth Stages of Labor

FIGURE 14.15 Crowning.

During the second stage of labor, an ideal position would be one that opens the pelvic outlet as wide as possible, provides a smooth pathway for the fetus to descend through the birth canal, takes advantage of gravity to assist the fetus to descend, and gives the mother a sense of being safe and in control of the labor process (Capogna, 2015a). Some suggestions for positions in the second stage include: • Lithotomy with feet up in stirrups: most convenient position for caregivers, although EBP findings do not support this position physiologically • Semi-sitting with pillows underneath knees, arms, and back • Lateral/side-lying with curved back and upper leg supported by partner • Sitting on birthing stool: opens pelvis, enhances the pull of gravity, and helps with pushing • Squatting/supported squatting: gives the woman a sense of control • Kneeling with hands on bed and knees comfortably apart Other important nursing interventions during the second stage include: • Providing continuous comfort measures such as mouth care, encouraging position changes, changing bed linen and underpads, and providing a quiet,

focused environment • Instructing the woman on the following bearing-down positions and techniques: • Pushing only when she feels an urge to do so • Delaying pushing for up to 90 minutes after complete dilation • Using abdominal muscles when bearing down • Using short pushes of 6 to 7 seconds • Focusing attention on the perineal area to visualize the newborn • Relaxing and conserving energy between contractions • Pushing several times with each contraction • Pushing with an open glottis and slight exhalation (Petrocnik & Marshall, 2015) • Continuing to monitor contraction and FHR patterns to identify problems • Providing brief, explicit directions throughout this stage • Continuing to provide psychosocial support by reassuring and coaching • Facilitating the upright position to encourage the fetus to descend • Continuing to assess blood pressure, pulse, respirations, uterine contractions, bearing-down efforts, FHR, and coping status of the client and her partner • Providing pain management if needed • Providing a continuous nursing presence • Offering praise for the client’s efforts • Preparing for and assisting with delivery by: • Notifying the health care provider of the estimated time frame for birth • Preparing the delivery bed and positioning client • Preparing the perineal area according to the facility’s protocol • Offering a mirror and adjusting it so the woman can watch the birth • Explaining all procedures and equipment to the client and her partner • Setting up delivery instruments needed while maintaining sterility • Using standard precautions during the birthing process to avoid body fluid splashes • Recording the time of birth, time of placenta, and type of birth

• Receiving newborn and transporting him or her to a warming environment, or covering the newborn with a warmed blanket on the woman’s abdomen • Providing initial care and assessment of the newborn (see the Birth section that follows) Sheila is completely dilated now and experiencing the urge to push. How can the nurse help Sheila with her pushing efforts? What additional interventions can the labor nurse offer Sheila now? In addition to encouraging Sheila to rest between pushing and offering praise for her efforts, what is the nurse’s role during the birthing process? BIRTH The second stage of labor ends with the birth of the newborn. The maternal position for birth varies from the standard lithotomy position to side-lying to squatting to standing or kneeling, depending on the birthing location, the woman’s preference, and standard protocols. Once the woman is positioned for birth, cleanse the vulva and perineal areas. The primary health care provider then takes charge after donning protective eyewear, masks, gowns, and gloves and performing hand hygiene. Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. As soon as the head emerges, the health care provider suctions the newborn’s mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium (Fig. 14.16). The umbilical cord is doubleclamped and cut between the clamps by the birth attendant or the woman’s partner if desired. With the first cries of the newborn, the second stage of labor ends. For care of the woman undergoing a surgical birth, the reader is referred to Chapter 21. In addition to encouraging Sheila to rest between pushing and offering praise for her efforts, what is the nurse’s role during the birthing process? IMMEDIATE CARE OF THE NEWBORN

Once birth takes place, the newborn is placed under a radiant warmer, dried, assessed, wrapped in warmed blankets, and placed on the woman’s abdomen for warmth and closeness. In some health care facilities, the newborn is placed on the woman’s abdomen immediately after birth and covered with a warmed blanket without being dried or assessed. In either scenario, the stability of the newborn dictates the location of aftercare. The nurse can also assist the mother with breast-feeding her newborn for the first time.

FIGURE 14.16 Suctioning the newborn immediately after birth.

Assessment of the newborn begins at the moment of birth and continues until the newborn is discharged. Drying the newborn and providing warmth to prevent heat loss by evaporation is essential to help support thermoregulation and provide stimulation. Placing the newborn under a radiant heat source and putting on a stockinette/knitted cap will further reduce heat loss after drying. Assess the newborn by assigning an Apgar score at 1 and 5 minutes. The Apgar score assesses five parameters—(1) heart rate (absent, slow, or fast),

(2)respiratory effort (absent, weak cry, or good strong yell), (3) muscle tone (limp, or lively and active), (4) response to irritation stimulus, and (5) color— that evaluate a newborn’s cardiorespiratory adaptation after birth. The parameters are arranged from the most important (heart rate) to the least important (color). The newborn is assigned a score of 0 to 2 in each of the five parameters. The purpose of the Apgar assessment is to evaluate the physiologic status of the newborn; see Chapter 18 for additional information on Apgar scoring. Secure two identification bands on the newborn’s wrist and ankle that match the band on the mother’s wrist to ensure the newborn’s identity. This identification process is completed in the birthing suite before anyone leaves the room. Some health care agencies also take an early photo of the newborn for identification in the event of abduction (National Center for Missing and Exploited Children [NCMEC], 2015).

FIGURE 14.17 An example of a security sensor applied to a newborn’s arm.

Other types of newborn security systems can also be used to prevent abduction. Some systems have sensors that are attached to the newborn’s identification bracelet or cord clamp. An alarm is set off if the bracelet or clamp activates receivers near exits. Others have an alarm that is activated when the sensor is removed from the newborn (Fig. 14.17). Even with the use of electronic sensors, the parents, nursing staff, and security personnel are responsible for prevention strategies and ensuring the safety and protection of all

newborns (NCMEC, 2015). Nurses can help in preventing newborn abduction by educating parents about abduction risks, using identically numbered bands on the baby and parents, by instructing couples to keep their newborn in their direct line of vision within their hospital room at all times, taking color photographs of the infant, wearing color photograph ID badges themselves, discouraging parents/families from publishing birth notices in the public media with mother’s name and address, controlling access to nursery/postpartum unit with locked doors, and utilizing infant security tags or abduction alarm systems (NCMEC, 2015). Sheila gave birth to a healthy 7-lb, 7-oz baby girl. She is eager to hold and nurse her newborn. What is the initial care of the newborn? How can the nurse meet the needs of both the newborn and Sheila, who is exhausted but eager to bond with her newborn?

Nursing Management During the Third Stage of Labor During the third stage of labor, strong uterine contractions continue at regular intervals under the continuing influence of oxytocin. The uterine muscle fibers shorten, or retract, with each contraction, leading to a gradual decrease in the size of the uterus, which helps shear the placenta away from its attachment site. The third stage is complete when the placenta is delivered. Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and observing for signs of placental separation, being available to assist with the delivery of the placenta, recording the time of expulsion and inspecting it for intactness. The nurse should also be assessing by palpating the uterus before and after placental expulsion. Three hormones play important roles in the third stage. During this stage the woman experiences peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the second stage of labor to aid with pushing begin falling. The hormone oxytocin causes uterine contractions and helps the woman to enact instinctive mothering behaviors such as holding the newborn close to her body and cuddling the baby. Skin-to-skin contact immediately after birth and the newborn’s first attempt at breast-feeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help the placenta to separate and the uterus to contract to prevent hemorrhage. Endorphins, the body’s natural opiates, produce an altered state of consciousness and aid in blocking out pain. In addition, the drop in adrenaline level from the second stage, which had kept the mother and baby alert at first contact, causes most women to shiver and feel cold shortly after giving birth.

Take Note! A crucial role for nurses during this time is to protect the natural hormonal process by ensuring unhurried and uninterrupted contact between mother and newborn after birth, providing warmed blankets to prevent shivering, and allowing skin-to-skin contact with initial breast-feeding.

Continuing Assessment During the Third Stage of Labor Assessment during the third stage of labor includes: • Monitoring placental separation by looking for the following signs: • Firmly contracting uterus • Change in uterine shape from discoid to globular ovoid • Sudden gush of dark blood from vaginal opening • Lengthening of umbilical cord protruding from vagina • Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) (Fig. 14.18) • Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave: • Firm fundus with bright-red blood trickling: laceration • Boggy fundus with red blood flowing: uterine atony • Boggy fundus with dark blood and clots: retained placenta • Inspecting the perineum for condition of episiotomy, if performed • Assessing for perineal lacerations and ensuring repair by birth attendant

Nursing Interventions Interventions during the third stage of labor include: • Describing the process of placental separation to the couple • Instructing the woman to push when signs of separation are apparent • Administering an oxytocic agent if ordered and indicated after placental expulsion • Providing support and information about episiotomy and/or laceration if applicable • Cleaning and assisting client into a comfortable position after birth, making sure to lift both legs out of stirrups (if used) simultaneously to prevent strain • Assess the woman’s knowledge of breast-feeding to determine educational needs • Instruct her about latching on, positioning, infant sucking and swallowing

• Repositioning the birthing bed to serve as a recovery bed if applicable • Assisting with transfer to the recovery area if applicable • Providing warmth by replacing warmed blankets over the woman • Applying an ice pack to the perineal area to provide comfort to episiotomy if indicated • Explaining what assessments will be carried out over the next hour and offering positive reinforcement for actions • Ascertaining any needs • Monitoring maternal physical status by assessing: • Vaginal bleeding: amount, consistency, and color • Vital signs: blood pressure, pulse, and respirations taken every 15 minutes • Uterine fundus, which should be firm, in the midline, and at the level of the umbilicus • Recording all birthing statistics and securing primary caregiver’s signature • Documenting birthing event in the birth book (official record of the facility that outlines every birth event), detailing any deviations

FIGURE 14.18 Placenta. A. Fetal side. B. Maternal side.

Nursing Management During the Fourth Stage of Labor The fourth stage of labor begins after the placenta is expelled and lasts up to 4 hours after birth, during which time recovery takes place. This recovery period may take place in the same room where the woman gave birth, in a separate recovery area, or in her postpartum room. During this stage, the woman’s body is beginning to undergo the many physiologic and psychological changes that occur after birth. The focus of nursing management during the fourth stage of labor involves frequent close observation for hemorrhage, provision of comfort measures, and promotion of family attachment.

Assessment Assessments during the fourth stage center on the woman’s vital signs, status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. During the first hour after birth, vital signs are taken every 15 minutes, then every 30 minutes for the next hour if needed. The woman’s blood pressure should remain stable and within normal range after giving birth. A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia. The pulse usually is typically slower (60 to 70 bpm) than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss. The blood pressure usually returns to its prepregnancy level and therefore is not a reliable early indicator of shock. Fever is indicative of dehydration (less than 100.4°F or 38°C) or infection (above 101°F), which may involve the genitourinary tract. Respiratory rate is usually between 16 and 24 breaths per minute and regular. Respirations should be unlabored unless there is an underlying preexisting respiratory condition. Assess fundal height, position, and firmness every 15 minutes during the first hour following birth. The fundus needs to remain firm to prevent excessive postpartum bleeding. The fundus should be firm (feels like the size and consistency of a grapefruit), located in the midline and below the umbilicus. If it is not firm (boggy), gently massage it until it is firm (see Nursing Procedure 22.1 for more information). Once firmness is obtained, stop massaging.

Take Note! If the fundus is displaced to the right of the midline, suspect a full bladder as the cause. The vagina and perineal areas are quite stretched and edematous following a vaginal birth. Assess the perineum, including the episiotomy if present, for possible hematoma formation. Suspect a hematoma if the woman reports excruciating pain or cannot void or if a mass is noted in the perineal area. Also assess for hemorrhoids, which can cause discomfort. Assess the woman’s comfort level frequently to determine the need for analgesia. Ask the woman to rate her pain on a scale of 1 to 10; it should be less than 3. If it is higher, further evaluation is needed to make sure there aren’t any deviations contributing to her discomfort. Assess vaginal discharge (lochia) every 15 minutes for the first hour and every 30 minutes for the next hour. Palpate the fundus at the same time to ascertain its firmness and help to estimate the amount of vaginal discharge. In addition, palpate the bladder for fullness, since many women receiving an epidural block experience limited sensation in the bladder region. Voiding should produce large amounts of urine (diuresis) each time. Palpating the woman’s bladder after each voiding helps in assessing it and ensuring complete emptying. A full bladder will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess.

Nursing Interventions Nursing interventions during the fourth stage might include: • Providing support and information to the woman regarding episiotomy repair and related pain relief and self-care measures • Applying an ice pack to the perineum to promote comfort and reduce swelling • Assisting with hygiene and perineal care; teaching the woman how to use the perineal bottle after each pad change and voiding; helping the woman into a new gown • Monitoring for return of sensation and ability to void (if regional anesthesia was used)

• Encouraging the woman to void by ambulating to the bathroom, listening to running water, or pouring warm water over the perineal area with the peribottle • Monitoring vital signs and fundal and lochia status every 15 minutes and documenting them • Assessing for postpartum hemorrhage and urinary retention via uterine palpation • Promoting comfort by offering analgesia for afterpains and warm blankets to reduce chilling • Offering fluids and nourishment if desired • Encouraging parent–infant attachment by providing privacy for the family • Being knowledgeable about and sensitive to typical cultural practices after birth • Assisting and encouraging the mother to nurse, if she chooses, during the recovery period to promote uterine firmness (the release of oxytocin from the posterior pituitary gland stimulates uterine contractions) • Teaching the woman how to assess her fundus for firmness periodically and to massage it if it is boggy • Describing the lochia flow and normal parameters to observe for postpartum • Teaching safety techniques to prevent newborn abduction • Demonstrating the use of the portable sitz bath as a comfort measure for her perineum if she had a laceration or an episiotomy repair • Explaining comfort/hygiene measures and when to use them • Assisting with ambulation when getting out of bed for the first time • Providing information about the routine on the mother–baby unit or nursery for her stay • Observing for signs of early parent–infant attachment: fingertip touch to palm touch to enfolding of the infant (Leonard, 2015; Green, 2016). The nurse’s role in labor and birth is a privileged one, supporting women at one of their most vulnerable times—childbirth. The nurse’s focus during this time should be on supporting, protecting, advocating and empowering women. The nurse should also provide informational support, which would allow the woman to realize her aspirations and goals by making decisions through

informed choice. Nurses make a long-term difference in the lives of childbearing women with small things they do for their clients that make a big difference to them. KEY CONCEPTS A nurse provides physical and emotional support during the labor and birth process to assist a woman to achieve her goals. When a woman is admitted to the labor and birth area, the admitting nurse must assess and evaluate the risk status of the pregnancy and initiate appropriate interventions to provide optimal care for the client. Completing an admission assessment includes taking a maternal health history; performing a physical assessment on the woman and fetus, including her emotional and psychosocial status; and obtaining the necessary laboratory studies. The nurse’s role in fetal assessment for labor and birth includes determining fetal well-being and interpreting signs and symptoms of possible compromise. Determining the fetal heart rate (FHR) pattern and assessing amniotic fluid characteristics are key. FHR can be assessed intermittently or continuously. Although the intermittent method allows the client to move about during labor, the information obtained intermittently does not provide a complete picture of fetal well-being from moment to moment. Assessment parameters of the FHR are classified as baseline rate, baseline variability, and periodic changes in the rate (accelerations and decelerations). The nurse monitoring the laboring client needs to be knowledgeable about which category the FHR pattern is in so that appropriate interventions can be instituted. For a Category III FHR pattern, the nurse should notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. In addition to interpreting assessment findings and initiating appropriate inventions for the laboring client, accurate and timely documentation must be carried out continuously. Today’s women have many safe nonpharmacologic and pharmacologic choices

for the management of pain during childbirth. They may be used individually or in combination to complement one another. Nursing management for the woman during labor and birth includes comfort measures, emotional support, information and instruction, advocacy, and support for the partner. Nursing care during the first stage of labor includes taking an admission history (reviewing the prenatal record), checking the results of routine laboratory work and special tests done during pregnancy, asking the woman about her childbirth preparation (birth plan, classes taken, coping skills), and completing a physical assessment of the woman to establish baseline values for future comparison. Nursing care during the second stage of labor focuses on supporting the woman and her partner in making decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing support and assistance, and encouraging the use of maternal positions that can enhance descent and reduce the pain. Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness. The focus of nursing management during the fourth stage of labor involves frequently observing the mother for hemorrhage, providing comfort measures, and promoting family attachment.

References and Recommended Readings Adams, J., Frawley, J., Steel, A., Broom, A., & Sibbritt, D. (2015). Use of pharmacological and nonpharmacological labor pain management techniques and their relationship to maternal and infant birth outcomes: Examination of a nationally representative sample of 1835 pregnant women. Midwifery, 31(4), 458–463. Agency for Healthcare Research and Quality [AHRQ] (2014). Intrapartum fetal heart rate monitoring: nomenclature, and general management principles. Retrieved from http://www.guideline.gov/content.aspx?id=14885 American College of Obstetricians and Gynecologists [ACOG] and Society for Maternal Fetal Medicine [SMFM] (2014). Safe prevention of the primary cesarean delivery. Obstetric Care Consensus 1, Obstetrics & Gynecology, 123, 693–711. American Hospital Association. (2014). RNs role in labor and delivery. Retrieved from http://www.aha.org/search?q=RNs+role+in+labor+and+delivery&start-date American Hospital Association [AHA] (2015). Prepared to care: The 24/7 role of America’s full-service hospitals. Retrieved from http://www.aha.org/content/00-10/PreparedToCareFinal.pdf American Pregnancy Association. (2015). Patterned breathing during labor. Retrieved from http://www.americanpregnancy.org/labornbirth/patternedbreathing.htm Anderson, L. (2014). Cultural competence in the nursing practice. Nursetogether. Retrieved from http://www.nursetogether.com/cultural-competence-in-the-nursing-practice Ashimi, O., Hoff, E., Sibai, B., & Hardwicke, R. (2015). 212: Should the current DHHS recommendations for use of antiretroviral drugs in maternal HIV-1 RNA undergo a review? An urban academic experience. American Journal of Obstetrics & Gynecology, 212(1), S119–S120. Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN]. (2015). Fetal heart monitoring: Principles and practices (5th ed.). Washington, DC: AWHONN. Badve, M., & Vallejo, M. C. (2015). Obstetric anesthesia. In Basic clinical anesthesia (pp. 501–527). New York, NY: Springer Publishers. Bowers, P. (2015). Cultural perspectives in childbearing. Nursing Spectrum. Retrieved from http://ce.nurse.com/ce263-60/cultural-perspectives-in-childbearing. Cahill, A. G., & Spain, J. (2015). Intrapartum fetal monitoring. Clinical Obstetrics and Gynecology, 58(2), 263–268. Callahan, T. L. (2016). Tarascon’s OB/GYN pocketbook. Burlington, MA: Jones & Bartlett Learning. Camorcia, M. (2015). The second and third stage of labor. In Epidural labor analgesia (pp. 103–119). Springer International Publishing. Capogna, G. (2015a). Humanization of childbirth and epidural analgesia. In Epidural labor analgesia (pp.

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Chapter WORKSHEET MULTIPLE CHOICE QUESTIONS 1. When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? a. Hold your breath and push through entire contraction. b. Use chest-breathing with the contraction. c. Pant and blow during each contraction. d. Wait until you feel the urge to push. 2. During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? a. Moderate amount of dark red lochia drainage on peripad b. Uterine fundus palpated to the right of the umbilicus c. An oral temperature reading of 100.6° F d. Perineal area bruised and edematous beneath her ice pack 3. When managing a client’s pain during labor, nurses should: a. Make sure the agents given do not prolong labor b. Know that all pain relief measures are similar c. Support the client’s decisions and requests d. Not recommend nonpharmacologic methods 4. When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: a. 15 to 30 minutes b. 5 to 10 minutes c. 45 to 60 minutes

d. 60 to 75 minutes 5. The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? a. Reposition the client on the left side. b. Begin 100% oxygen via face mask. c. Document this as indicating a normal pattern. d. Call the health care provider immediately. 6. By the end of the second stage of labor, the nurse would expect which of the following events? The a. cervix is fully dilated and effaced b. placenta is detached and expelled c. fetus is born and on mother’s chest d. woman to request pain medication 7. Which of the following practices would not be included in a physiologic birth? a. Early induction of labor 25 were recruited, stratified by BMI and randomized to one of three groups with follow-up to 6 months postpartum. Women received a dietary intervention with or without breast-feeding support from a lactation consultant. All participants initiated breast-feeding, but the group that had lactation support had a longer duration of breast-feeding than the group without the lactation support. In addition, the women with longer breast-feeding duration, also loss the most weight during the 6-month period.

Findings The study provided evidence to support the feasibility of providing overweight and obese women with targeted dietary advice and breast-feeding support to improve weight and breast-feeding outcomes.

Nursing Implications Based on the findings of this study, nurses can recommend to their postpartum mothers desiring to lose their pregnancy weight should be encouraged to breast-feed and sustain it for at least 6 months to lose their pregnancy weight gained. Research findings associate breast-feeding with postpartum weight loss due to the increase in women’s metabolic rates which burn calories. This information should be reported to postpartum mothers desiring to lose weight and breast-feed. Overall, if gained weight through the pregnancy isn’t lost, their risk of cardiovascular diseases, diabetes, hypertension, and cancer will be increased as they age. The weight loss will help prevent these conditions or at the very least reduce their risks. Adapted from Martin, J., MacDonald-Wicks, L., Hure, A., Smith, R., & Collins, C. E. (2015). Reducing postpartum weight retention and improving breastfeeding outcomes in overweight women: A pilot randomized controlled trial. Nutrients, 7(3), 1464–1479.

Global Health of Childbearing Women Globalization has changed our society in numerous ways, yet the health of women is remaining stagnant or growing worse in many parts of the world. Many women in developing counties are denied their fundamental right to enjoy a complete state of health as defined by the World Health Organization (BoydJudson & James, 2014). More than half a million women die each year from complications during and after childbirth (bleeding and infections), the vast majority of them in Africa and Asia (Webber & Chirangi, 2014). Women throughout the world continue to face enormous obstacles in attempting to access obstetric care. Skilled attendance at childbirth is critical for decreasing maternal and neonatal mortality, yet many women in developing countries give birth outside health facilities, without skilled help. Nurses throughout the world can help advocate for cost-effective, evidence-based interventions to prevent and battle complications from childbirth to save women’s lives. The challenge is to guarantee that every pregnant woman who needs care gets it. Nurses can make a difference outside their own country’s borders by advocating for all international women through their governmental

political systems and encouraging those governments to offer help and save lives.

Lactation Lactation is the secretion of milk by the breasts. It is thought to be brought about by the interaction of progesterone, estrogen, prolactin, and oxytocin. Breast milk typically appears within 4 to 5 days after childbirth. BREAST-FEEDING Breast-feeding is a dynamic process, which requires coupling between periodic motions of the infant’s jaws, undulation of the tongue, and breast milk ejection reflex. All mechanisms must be coordinated to be successful. All major health organizations recommend breast-feeding. The American Academy of Pediatrics recommends exclusive breast-feeding for 6 months, followed by the introduction of appropriate complementary foods and continued breast-feeding to 1 year and beyond (American Academy of Pediatrics [AAP], 2015). This recommendation is considered to be the standard of care today. Nurses have an important role in promoting, supporting, and protecting breast-feeding. Proper positioning, latching-on, sucking, and swallowing are the foundation for successful breastfeeding. Although breast-feeding is recommended by international and national organizations, the nurse must respect and support all mothers in either of the infant feeding methods chosen. During pregnancy, the breasts increase in size and functional ability in preparation for breast-feeding. Estrogen stimulates growth of the milk collection (ductal) system, whereas progesterone stimulates growth of the milk production system. Within the first month of gestation, the ducts of the mammary glands grow branches, forming more lobules and alveoli. These structural changes make the breasts larger, more tender, and heavy. Each breast gains nearly 1 lb in weight by term, the glandular cells fill with secretions, blood vessels increase in number, and the amounts of connective tissue and fat cells increase (Engel et al., 2015). Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high

levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the glandular cells to secrete milk instead of colostrum. This takes place within 4 to 5 days after giving birth. Oxytocin acts so that milk can be ejected from the alveoli to the nipple. Therefore, sucking by the newborn will release milk. A decrease in the quality of stimulation causes a decrease in prolactin surges and thus a decrease in milk production. Prolactin levels increase in response to nipple stimulation during feedings. Prolactin and oxytocin result in milk production if stimulated by sucking (Stuebe et al., 2015) (Fig. 15.3). If the stimulus (sucking) is not present, as with a woman who is not breast-feeding, breast engorgement and milk production will subside within days postpartum. Skin-to-skin contact during the first hour following birth is the gold standard to initiate breast-feeding, if the mother decides this is the method of feeding for her newborn. Researchers realized that a newborn’s instinct was to seek nourishment after birth. They move on their mother’s abdomen up to her breast instinctively. Researchers term this movement the breast crawl that helps initiate breastfeeding immediately after childbirth. This instinct occurs when a newborn, left undisturbed and skin-to-skin on the mother’s trunk following birth, moves toward her mother’s breast for the purpose of locating and self-attaching for the first feeding. From there, the newborn uses leg and arm movements to propel her/himself toward the breast. Upon reaching the sternum, the newborn will bounce her/his head up and down and side to side. As the newborn approaches the nipple, her/his mouth opens and, after several attempts, latch-on and suckling take place. Newborns have senses and skills that enable early initiation of feeding at the breast. Nurses can help facilitate the breast crawl as a continuation of the birthing process. Nurses have a responsibility to promote the health of their childbearing families and provide evidence-based care. Encouraging use of the breast crawl can be the first step in health promotion for every newborn (Zanardo & Straface, 2015). Breast milk production can be summarized as follows: • Prolactin levels increase at term with a decrease in estrogen and progesterone levels. • Estrogen and progesterone levels decrease after the placenta is delivered. • Prolactin is released from the anterior pituitary gland and initiates milk production. • Oxytocin is released from the posterior pituitary gland to promote milk let-

down. • Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release (Wambach & Riordan, 2014).

FIGURE 15.3 Physiology of lactation.

Typically, during the first 2 days after birth, the breasts are soft and nontender. The woman also may report a tingling sensation in both breasts, which is the “let-down reflex” that occurs immediately before or during breast-feeding. After this time, breast changes depend on whether the mother is breast-feeding or taking measures to prevent lactation. Engorgement is a postnatal physiologic painful condition in which distension and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation (Fig. 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours (Alekseev, Vladimir, & Nadezhda, 2015). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about

24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. They are temporarily full, tender, and very uncomfortable until the milk supply is ready. Frequent emptying of the breasts helps to minimize discomfort and resolve engorgement. Standing in a warm shower or applying warm compresses immediately before feedings will help to soften the breasts and nipples in order to allow the newborn to latch on more easily. Treatments to reduce the pain of breast engorgement include heat or cold applications, cabbage leaf compresses, breast massage and milk expression, ultrasound, breast pumping, and anti-inflammatory agents (King et al., 2015). A nonprescription anti-inflammatory medication can also be taken for the breast discomfort and swelling resulting from engorgement. These measures will also enhance the let-down reflex. Between feedings, applying cold compresses to the breasts helps to reduce swelling. To maintain milk supply, the breasts need to be stimulated by a nursing infant, a breast pump, or manual expression of the milk (Fig. 15.5).

FIGURE 15.4 A. Image of engorged breasts. Note swelling and inflammation of both breasts. B. Breast engorgement can disrupt breast-feeding: (1) When sucking at a normal breast, the infant’s lips compress the areola and fit neatly against the sides of the nipple. The infant also has adequate room to breathe. (2) When a breast is engorged, however, the infant has difficulty grasping the nipple and breathing ability is compromised. (From Pillitteri, A. [2014]. Maternal and child nursing. (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.)

Remember Betsy, with the breast discomfort? The lactation consultant explained that she was experiencing normal breast engorgement and offered several suggestions to help her. What relief measures might she have

suggested? What reassurance can be given to Betsy at this time? SUPPRESSING LACTATION Various pharmacologic and nonpharmacologic interventions have been used to suppress lactation after childbirth and relieve associated symptoms. Despite the large volume of literature on the subject, there is currently no universal guideline on the most appropriate approach for suppressing lactation in postpartum women (Cunningham et al., 2014). It is estimated that more than 30% of women in the United States do not breast-feed their infants, and a larger proportion discontinues breast-feeding within 2 weeks of childbirth (Senie, 2014). Although physiologic cessation of lactation eventually occurs in the absence of physical stimulus such as infant suckling, a large number of women experience moderate to severe milk leakage and discomfort before lactation ceases.

FIGURE 15.5 Nurse instructs the new breast-feeding mother about use of a breast pump. (Copyright B. Proud.)

Up to two thirds of non-breast-feeding women experience moderate to severe engorgement and breast pain when no treatment is applied (Spencer, 2015). If a woman does not desire to breast-feed, some relief measures include wearing a tight, supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, avoiding sexual stimulation, and not stimulating the breasts by squeezing or manually expressing milk from the nipples. In addition, avoiding exposing the breasts to warmth (e.g., a hot shower) will help relieve breast engorgement. In women who are not breast-feeding,

engorgement typically subsides within 2 to 3 days with application of these measures.

Ovulation and Return of Menstruation Changing hormone levels constantly interact with one another to produce bodily changes. Four major hormones are influential during the postpartum period: estrogen, progesterone, prolactin, and oxytocin. Estrogen plays a major role during pregnancy, but levels drop profoundly at birth and reach their lowest level a week into the postpartum period. Progesterone quiets the uterus to prevent a preterm birth during pregnancy, and its increasing levels during pregnancy prevent lactation from starting before birth takes place. As with estrogen, progesterone levels decrease dramatically after birth and are undetectable 72 hours after birth. Progesterone levels are reestablished with the first menstrual cycle (Creasy et al., 2014). During the postpartum period, oxytocin stimulates the uterus to contract during the breast-feeding session and for as long as 20 minutes after each feeding. Oxytocin also acts on the breast by eliciting the milk let-down reflex during breast-feeding. Prolactin is also associated with the breast-feeding process by stimulating milk production. In women who breast-feed, prolactin levels remain elevated into the sixth week after birth (Bope & Kellerman, 2015). The levels of prolactin fluctuate in proportion to nipple stimulation. Prolactin levels decrease in nonlactating women, reaching prepregnant levels by the third postpartum week. High levels of prolactin have been found to delay ovulation by inhibiting ovarian response to follicle-stimulating hormone (Bernard et al., 2015). The timing of first menses and ovulation after birth differs between women who are breast-feeding and women who are not breast-feeding. For nonlactating women, menstruation may resume as early as 7 to 9 weeks after giving birth, but the majority take up to 3 months, with the first cycle being anovulatory (Barrett et al., 2014). The return of menses in the lactating woman depends on breastfeeding frequency and duration. It can return any time after childbirth, depending on whether the woman is exclusively breast-feeding or supplementing with formula.

Take Note!

Ovulation may occur before menstruation. Therefore, breast-feeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and whose infant is younger than 6 months old (Alexander et al., 2014). Betsy tries several of the measures the lactation consultant suggested to relieve her breast discomfort, but is still having heaviness and pain. She feels discouraged and tells the nurse she is thinking of reducing her breast-feeding and using formula to feed her newborn. Is that a good choice? Why or why not? What interventions will help Betsy get through this difficult time?

CULTURAL CONSIDERATIONS FOR THE POSTPARTUM PERIOD Cultures vary in their postpartum beliefs, practices, and customs. Nurses practice in an increasingly multicultural society. Therefore, they must be open, respectful, nonjudgmental, and willing to learn about ethnically diverse populations. Although childbirth and the postpartum period are unique experiences for each individual woman, how the woman perceives and makes meaning of them is culturally defined. Somali women are highly regarded in Somali society for their roles as mothers. Postpartum women stay at home and refrain from sexual activity for 40 days. At the end of 40 days, there is a celebration and this typically marks the first time the mother and infant have left their home since childbirth. The majority of Somalian and Arab women breast-feed and do so for extended periods of time (Wojnar & Narruhn, 2016). Nurses need to offer early breast feeding instruction to support their efforts while still in the hospital setting before discharge.

Balance of Hot and Cold Two areas that are significantly different from Western culture involve beliefs about the balance of hot and cold and confinement after childbirth. Vietnamese women view the postpartum period as a cold state (duong) and protect themselves through warmth. Cultural practices include warm water for hygiene and stimulation of lactation, consuming warm foods, and staying indoors. In the United States, childbearing and recovery are viewed as healthy states and mothers receive little formal support for both their recovery and infant care. In China, childbearing and postpartum are viewed as states which disturb the normal health balance between yin and yang. In order to restore balance in health, postpartum women engage in practices for a month related to the maternal role, physical activity, maintenance of body warmth, and certain food consumption that will restore their balance. Recent research findings in a small sample of Chinese women found that postpartum confinement negatively correlated with aerobic endurance and positively correlated with depression. These findings may challenge the assumption that practices of confinement are healthy for Chinese women’s recovery after childbirth (Liu, Maloni, & Petrini, 2014). For many cultures, good health requires the balancing of hot and cold substances. Because childbirth involves the loss of blood, which is considered hot, the postpartum period is considered cold, so the mother must balance that with the intake of hot food. Foods consumed should be hot in nature, and cold foods, such as fruits and vegetables, avoided. Western practices frequently use cold packs or sitz baths to reduce perineal swelling and discomfort. These practices are not acceptable to women of many cultures and can be viewed as harmful. Hot–cold beliefs are common among Latin American, African, and Asian people (Purnell, 2014). To reduce infant and mother vulnerability and potential illness, women may practice a month-long confinement period after childbirth. During this confinement period, new mothers rest and recuperate. The postpartum period is a time to avoid cold—both in temperature and foods. Women are kept warm, stay inside to prevent becoming chilled, bathe infrequently, and avoid exercise (Rice & Manderson, 2014).

Postpartum Cultural Beliefs With increasing multiculturalism in the United States, understanding various cultures’ views of the postnatal period as it relates to their recovery and wellbeing after childbirth is important for all nurses. Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene (sponge baths, perineal care), exercise, and balanced nutrition, while remaining respectful of the cultural significance of these practices. The best approach is to ask each woman to describe what cultural practices are important to her and plan accordingly.

PSYCHOLOGICAL ADAPTATIONS The process of becoming a mother requires extensive psychological, social, and physical work. Women experience heightened vulnerability and face tremendous challenges as they make this transition. Nurses have a remarkable opportunity to help women learn, gain confidence, and experience growth as they assume the mother identity. The transition to parenthood, while an exciting time to celebrate the life of their child, causes parents to face new challenges such as physical exhaustion, role overload, and less time for themselves and their partners (Velotti, Castellano, & Zavattini, 2015). Mothers’ and fathers’ experiences of pregnancy are necessarily different, and this difference continues after childbirth as they both adjust to their new parenting roles. Many couples struggle to adapt to parenthood. Parenting involves caring for infants physically and emotionally to foster the growth and development of responsible, caring adults. A substantial body of research finds no biologic-based differences between mothers and fathers in sensitivity to infants, capacity to provide care or acquisition of parenting skills. Within 15 minutes of holding a newborn, men experience raised levels of oxytocin, cortisol, and prolactin. The increased levels of these nurturing hormones are the same in men and women exposed to infants (Davies, 2015). Other members of the newborn’s family, such as siblings and grandparents, also experience changes related to the birth of the newborn (see Chapter 16). Early parent–infant contact after birth improves attachment behaviors.

Parental Attachment Behaviors The postpartum period is a unique time distinguished by the inseparable relationship parents have with their newborn. To enable an attachment to be built, closeness of this family unit is essential. Attachment is the formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions. Attachment between a woman and her newborn has lifelong implications (King et al., 2015). Maternal attachment has the potential to affect both child development and parenting. The bond between a parent and their newborn is one of strength, power, and potential. Attachment begins before birth, during the prenatal period where acceptance and nurturing of the growing fetus takes place. It continues after giving birth as parents learn to recognize their newborn’s cues, adapt to the newborn’s behaviors and responses, and meet their newborn’s needs. Several factors take place during the early postpartum period that can have a large influence on the attachment/bonding that occurs during this time. Oxytocin plays an essential role in the chemistry aspect of bonding, and its effects can be enhanced by skin-to-skin contact, breast-feeding, eye contact, social vocalizations, maternal and milk odors, which are soothing for the newborn, and newborn message during the first postpartum hour (Buckley, 2015; Hutcheson & Cheeseman, 2015). Early and sustained contact between newborns and their parents is vital for initiating their relationship. Nurses play a crucial role in assisting the attachment process by promoting early parent–newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers to enhance parent–newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breast-feeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care. The process of attachment is complex and is influenced by many factors including environmental circumstances, the newborn’s health status, and the quality of nursing care (Buckley, 2015). Nurses need to minimize parent–

newborn separation by promoting parent–newborn interactions through kangaroo care, breast-feeding, and participation in their newborn care. Nurses who provide positive psychosocial support and clear communication to parents will help support the attachment process within family units.

Maternal Psychological Adaptations Childbirth is supposed to be the most joyous period in a woman’s life and involves the almost spiritual experience of giving birth and being able to give life to another being. For many, this can be a life-changing event and through the centuries has been anticipated with excitement and joy and has even been referred to as a blessing. In reality, childbirth and child rearing are very stressful, financially challenging, and emotionally demanding.

Mood Disorders Many people consider childbirth a time of happiness and well-being, but it is common for women to experience changes in their mood during this time. This may include being fatigued, irritable or worried, and frequently these mood symptoms become severe enough to need medical intervention. In the postpartum period, mood disorders can be divided into three distinct entities in ascending order of severity: maternal (baby) blues, postpartum depression, and psychosis. These disorders, however, have not been clearly demarcated and it is a matter of much debate whether they are discrete disorders or a single disorder that ranges along a continuum of severity (Finley & Brizendine, 2015). Up to 85% of new mothers suffer from the short-lived postpartum mood disorder termed “baby blues” or maternal blues, which are characterized by mild depressive symptoms, anxiety, irritability, mood swings, lose their appetite, have trouble sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue (Flynn, 2015). The “blues” typically peak on postpartum days 4 and 5, may last hours to days, and usually resolve by day 10. Although these symptoms may be distressing, they do not reflect psychopathology, and they typically do not affect the mother’s ability to function and care for her child. For additional information, see Chapter 22.

Phases of Maternal Adaptation to Parenthood Parenthood is a highly anticipated and positive event for most women. Society has constructed many ideal images of motherhood, giving standards for women to live up to, and frequently setting them up for disappointment. Most women are able to experience this mismatch between their ideal and actual self and adapt with minimal discrepancy (Adams, 2015). The woman experiences a

variety of responses as she adjusts to a new family member and to postpartum discomforts, changes in her body image, and the reality of change in her life. In the early 1960s, Reva Rubin identified three phases that a mother goes through to adjust to her new maternal role. Rubin’s maternal role framework can be used to monitor the client’s progress as she “tries on” her new role as a mother. The absence of these processes or inability to progress through the phases satisfactorily may impede the appropriate development of the maternal role (Rubin, 1984). Although Rubin’s maternal role development theories are of value, some of her observations regarding the length of each phase may not be completely relevant for the contemporary woman of the 21st century. Today, many women know their infant’s gender, have “seen” their fetus in utero through four-dimensional ultrasound, and have a working knowledge of childbirth and child care. They are less passive than in years past and progress through the phases of attaining the maternal role at a much faster pace than Rubin would have imagined. Still, Rubin’s framework is timeless for assessing and monitoring expected role behaviors when planning care and appropriate interventions. TAKING-IN PHASE The taking-in phase is the time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. This phase is characterized by dependent behavior. During the first 24 to 48 hours after giving birth, mothers often assume a very passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse to make decisions for them concerning activities and care. They spend time recounting their labor experience to anyone who will listen. Such actions help the mother integrate the birth experience into reality—that is, the pregnancy is over and the newborn is now a unique individual, separate from herself. When interacting with the newborn, new mothers spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn, such as “he has my nose” or “his fingers are long like his father’s” (Fig. 15.6).

Take Note! The taking-in phase typically lasts 1 to 2 days and may be the only phase observed by nurses in the hospital setting because of the shortened postpartum stays that are the norm today.

FIGURE 15.6 Mother bonding with newborn during the taking-in phase.

TAKING-HOLD PHASE The taking-hold phase, the second phase of maternal adaptation, is characterized by dependent and independent maternal behavior. This phase typically starts on the second to third day postpartum and may last several weeks. As the client regains control over her bodily functions during the next few days, she will be taking hold and becoming preoccupied with the present. She will be particularly concerned about her health, the infant’s condition, and her ability to care for her or him. She demonstrates increased autonomy and mastery of her own body’s functioning, and a desire to take charge with support and help from others. She will show independence by caring for herself and learning to care for her newborn, but she still requires assurance that she is doing well as a mother. She expresses a strong interest in caring for the infant by herself. LETTING-GO PHASE In the letting-go phase, the third phase of maternal adaptation, the woman reestablishes relationships with other people. She adapts to parenthood through her new role as a mother. She assumes the responsibility and care of the newborn with a bit more confidence now (Edelman, Kudzma, & Mandle, 2014). The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. She establishes a lifestyle that includes the infant. The mother

relinquishes the fantasy infant and accepts the real one. Nurses have recognized the importance of the process of becoming a mother (BAM) to maternal–infant nursing since Rubin’s report on maternal role attainment (MRA). Mothers’ perceptions of their competence or confidence, or both, in mothering and their expressions of love for their infants included age, relationship with the father, socioeconomic status, birth experience, experienced stress, available support, personality traits, self-concept, child-rearing attitudes, role strain, health status, preparation during pregnancy, relationships with own mother, depression, and anxiety. Infant variables identified as influencing MRA/BAM include appearance, responsiveness, temperament, and health status (DiPietro et al., 2015). More current research has led to renaming the four stages a woman progresses through in establishing a maternal identity in BAM: 1. Commitment, attachment to the unborn baby, and preparation for delivery and motherhood during pregnancy 2. Acquaintance/attachment to the infant, learning to care for the infant, and physical restoration during the first 2 to 6 weeks following birth 3. Moving toward a new normal 4. Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months). The mother feels self-confident and competent in her mothering and expresses love for and pleasure interacting with her infant (Mercer & Walker, 2006) The woman’s work in the first stage is to make a commitment to the pregnancy and to the safe birth and care of her unborn child. This commitment is associated with a positive adaptation to motherhood. During the second stage while the mother is placing the infant in her family context and learning how to care for her infant, her attachment and attitude toward her infant, and her selfconfidence or sense of competence in mothering, or both, consistently indicate an interdependence of these two variables. The nursing care provided during the first two stages is especially important in assisting mothers as they begin to mother. Follow-up is needed as mothers move toward a new normal and recognize a transformation of self in BAM can continue to reinforce their capabilities (Mercer, 2006). To foster maternal role attainment, three specific interventions for nurses were identified in a review of the literature (Ferrarello & Hatfield, 2014). First, instructions about infant care and the infant’s capabilities are more effective if

they are specifically focused on that particular mother’s infant. Second, mothers prefer live classes rather than videotapes so they can ask questions. In short, interactive nurse–client relationships are associated with positive maternal growth. Third, identifying barriers that reduce skin-to-skin periods of mother-toinfant during the postpartum hospital stay and intervening to reduce them have implications for both maternal role development and breast-feeding success, if she has chosen this method. Providing times for skin-to-skin mother and infant contact has a positive impact on the long-term health of both. Nurses who interact with clients long term during pregnancy, childbirth and during well child care help build maternal competence. Pregnancy, birth, and becoming a mother collectively represent a critical period of physical and emotional upheaval in a woman’s life. The need for a holistic care approach that supports the emotional and physical health of the dyad is imperative (Spiteri et al., 2014). Transition to motherhood theories (Rubin and Mercer) describe women in a prescribed role; that of being a mother and indeed a predetermined type of mother. In that sense transition to motherhood theory is baby-centered. New theories need to be developed that are woman-centered and conceptualize the woman as an embodied self who is powerful in her own life.

Partner Psychological Adaptations For partners, whether they are husbands, significant others, boyfriends, same-sex life partners, or just friends, becoming a parent or just sharing the childbirth experience can be a perplexing time as well as a time of great change. This transition is influenced by many factors, including participation in childbirth, relationships with significant others, competence in child care, the family role organization, the individual’s cultural background, and the method of infant feeding. The transition from being merely a partner to being a parent can propel many partners to reorganize their lifestyles. During the postpartum period, partners frequently find themselves struggling to balance personal and work needs with the new demands of parent status and their new self-image. The complexities of the transitional process involved in forging a parenthood identity can be viewed at three different levels: readjustment to a new self-image, formation of a triadic family relationship, and adaptation to redefining themselves and their relationship with their partner: the “more united tag team” (Halford, Petch, & Creedy, 2015). Nurses can play a key role in supporting a partner’s transition to parenthood by keeping partners informed about birth and postpartum routines, reporting on their newborn’s health status, and reviewing infant development. They can also contribute by creating participative space for new partners during the postpartum period. This can be achieved, for example, by helping partners take on their new role by supporting and promoting their degree of involvement in the process. They can also be encouraged to actively participate in caring for, and maintaining contact with, their newborns.

Take Note! Most research findings stress the importance of early contact between the partner or significant other and the newborn, as well as participation in infant care activities, to foster the relationship (Nolan, 2015). Infants have a powerful effect on their parents and others, who become intensely involved with them (Fig. 15.7). The father’s or significant other’s

developing bond with the newborn—a time of intense absorption, preoccupation, and interest—is called engrossment.

Engrossment Engrossment is characterized by seven behaviors: 1. Visual awareness of the newborn—the partner perceives the newborn as attractive, pretty, or beautiful. 2. Tactile awareness of the newborn—the partner has a desire to touch or hold the newborn and considers this activity to be pleasurable. 3. Perception of the newborn as perfect—the partner does not “see” any imperfections. 4. Strong attraction to the newborn—the partner focuses all attention on the newborn when they are in the room. 5. Awareness of distinct features of the newborn—the partner can distinguish his/her newborn from others in the nursery. 6. Extreme elation—the partner feels a “high” after the birth of his/her child. 7. Increased sense of self-esteem—the partner feels proud, “bigger,” more mature, and older after the birth of his/her child (Sears & Sears, 2015).

FIGURE 15.7 Engrossment of the father and his newborn.

Frequently, partners are portrayed as well-meaning but bumbling when caring for newborns. However, they have their own unique way of relating to their newborns and can become as nurturing as mothers. A partner’s nurturing responses may be less automatic and slower to unfold than a mother’s, but they are capable of a strong bonding attachment to their newborns (Sears & Sears, 2015). Encouraging partners to express their feelings by seeing, touching, and holding their son or daughter and by cuddling, talking to, and feeding him or her will help to cement this new relationship. Reinforcement of this engrossing behavior helps partners to make a positive attachment during this critical period.

Three-Stage Role Development Process Similar to mothers, partners also go through a predictable three-stage process during the first 3 weeks as they too “try on” their roles as parents. The three stages are expectations, reality, and transition to mastery (Sears & Sears, 2015). STAGE 1: EXPECTATIONS New partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many partners may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. For some, it is an eye-opening experience. STAGE 2: REALITY Stage 2 (reality) occurs when partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn’s care and yet do not feel prepared to do so. Some find parenting fun but at the same time do not feel fully prepared to take on that role. Partner’s stress, irritability and frustration in the days, weeks, and months after the birth of their child can turn into depression, just like new maternal experience. Unfortunately, partners rarely discuss their feelings or ask for help, especially during a time when they are supposed to be the “strong one” for the new mother. Depression in partners can cause marital conflicts, reckless or violent behavior, withdrawn parental interactions with the newborn, poor job performance, and substance abuse. In addition, paternal depression following childbirth can have a detrimental effect on a couple’s relationship, the parent– child relationship, and on their children’s future development (Sethna et al.,

2015). Risk factors for partner postpartum depression include previous history of depression, financial problems, a poor relationship with his/her partner, and an unplanned pregnancy. Symptoms of depression appear 1 to 3 weeks after birth and can include feelings of being very stressed and anxious, being discouraged, fatigued, resentment toward the infant and the attention he or she is getting, and headaches. Partners experiencing these symptoms should understand that it is not a sign of weakness and professional help can be helpful for them. STAGE 3: TRANSITION TO MASTERY In stage 3 (transition to mastery), the partner makes a conscious decision to take control and be at the center of his/her newborn’s life regardless of his/her preparedness. This adjustment period is similar to that of the mother’s letting-go phase, when she incorporates the newest member into the family. KEY CONCEPTS The puerperium period refers to the first 6 weeks after delivery. During this period, the mother experiences many physiologic and psychological adaptations to return her to the prepregnant state. Involution involves three processes: contraction of muscle fibers to reduce stretched ones, catabolism (which reduces enlarged, individual cells), and regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed in lochia. Lochia passes through three stages: lochia rubra, lochia serosa, and lochia alba during the postpartum period. Maternal blood plasma volume decreases rapidly after birth and returns to normal within 4 weeks postpartum. Reva Rubin (1984) identified three phases the mother goes through to adjust to her new maternal role: the taking-in, taking-hold, and letting-go phase. The transition to fatherhood is influenced by many factors, including participation in childbirth, relationships with significant others, competence in child care, the family role organization, the father’s cultural background, and the method of infant feeding. Like mothers, partners go through a predictable three-stage process during the first 3 weeks as they too “try on” their roles as f partners. The three stages

include expectations, reality, and transition to mastery.

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Nascimento, S., Pudwell, J., Surita, F., Adamo, K., & Smith, G. (2014). The effect of physical exercise strategies on weight loss in postpartum women: a systematic review and meta-analysis. International Journal of Obesity, 38(5), 626–635. Neville, C., McKinley, M., Holmes, V., Spence, D., & Woodside, J. (2014). The relationship between breastfeeding and postpartum weight change—a systematic review and critical evaluation. International Journal of Obesity, 38(4), 577–590. Nolan, M. (2015). Why it is important to involve new fathers in the care of their child: Mary Nolan explores research into the often-neglected role of men and suggests how primary care nurses can develop services to increase their involvement. Primary Health Care, 25(3), 18–23. Norwitz, E. R., & Schorge, J. O. (2015). Obstetrics & gynecology at a glance (5th ed.). Oxford, UK: WileyBlackwell. Parpaglioni, R. (2015). Anatomo-physiological changes during labor and after delivery. In Epidural labor analgesia (pp. 11–20). Switzerland: Springer International Publishing. Purnell, L. D. (2014). Guide to culturally competent health care (3rd ed.). Philadelphia, PA: F.A. Davis. Rice, P. L., & Manderson, L. (2014). Maternity and reproductive health in Asian societies. Abingdon, Oxon: Routledge. Rubin, R. (1984). Maternal identity and the maternal experience. New York, NY: Springer. Sears, R. W., & Sears, J. M. (2015). Ask Dr. Sears: Father-newborn bonding. Retrieved from http://www.askdrsears.com/topics/pregnancy-childbirth/tenth-month-post-partum/bonding-with-yournewborn/father-newborn-bonding. Senie, R. T. (2014). Epidemiology of women’s health. Burlington, MA: Jones & Bartlett Learning. Sethna, V., Murray, L., Netsi, E., Psychogiou, L., & Ramchandani, P. G. (2015). Paternal depression in the postnatal period and early father–infant interactions. Parenting, 15(1), 1–8. Spencer, B. (2015). Medications and breastfeeding for mothers with chronic illness. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(4), 543–552. Spiliopoulos, M., & Mastrogiannis, D. (2014). Normal and abnormal puerperium. eMedicine, Retrieved from http://emedicine.medscape.com/article/260187-overview#a1. Spiteri, G., Borg Xuereb, R., Carrick-Sen, D., Kaner, E., & Martin, C. R. (2014). Preparation for parenthood: a concept analysis. Journal of Reproductive & Infant Psychology, 32(2), 148–165. Stuebe, A. M., Meltzer-Brody, S., Pearson, B., Pedersen, C., & Grewen, K. (2015). Maternal neuroendocrine serum levels in exclusively breastfeeding mothers. Breastfeeding Medicine, 10(4), 197– 202. Velotti, P., Castellano, R., & Zavattini, G. C. (2015). Adjustment of couples following childbirth. European Psychologist, 16, 1–10 Wambach, K., & Riordan, J. (2014). Breastfeeding and human lactation (5th ed.). Burlington, MA: Jones and Bartlett Learning.

Webber, G. C., & Chirangi, B. (2014). Women’s health in women’s hands: A pilot study assessing the feasibility of providing women with medications to reduce postpartum hemorrhage and sepsis in rural Tanzania. Health Care for Women International, 35(7–9), 758–770. Wojnar, D. M., & Narruhn, R. A. (2016). Transcultural aspects of perinatal health care of Somali women. Caring for the vulnerable (4th ed., pp. 287–302). Burlington, MA: Jones & Bartlett Learning. Zanardo, V., & Straface, G. (2015). The higher temperature in the areola supports the natural progression of the birth to breastfeeding continuum. PLoS One, 10(3), e0118774.

CHAPTER WORKSHEET MULTIPLE CHOICE QUESTIONS 1. Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement? a. An increase in blood and lymph supply to the breasts b. An increase in estrogen and progesterone levels c. Colostrum production increases dramatically d. Fluid retention in the breasts due to the intravenous fluids given during labor 2. In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman’s behavior to be characterized as which of the following? a. Gaining self-confidence b. Adjusting to her new relationships c. Being passive and dependent d. Resuming control over her life 3. The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the after-pains she is experiencing can be the result of which of the following? a. Abdominal cramping is a sign of endometriosis b. A small infant weighing less than 8 lb

c. Pregnancies that were too closely spaced d. Contractions of the uterus after birth 4. The nurse would expect a postpartum woman to demonstrate lochia in which sequence? a. Rubra, alba, serosa b. Rubra, serosa, alba c. Serosa, alba, rubra d. Alba, rubra, serosa 5. The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings by the nurse would be expected? a. Cream-colored lochia; uterus above the umbilicus b. Bright-red lochia with clots; uterus 2 fingerbreadths below umbilicus c. Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus d. Yellow, mucousy lochia; uterus at the level of the umbilicus 6. Prioritize the postpartum mother’s needs 4 hours after giving birth by placing a number 1, 2, 3, or 4 in the blank before each need. a. _________ Learn how to hold and cuddle the infant. b. _________Watch a baby bath demonstration given by the nurse. c. _________ Sleep and rest without being disturbed for a few hours. d. _________ Interaction time (first 30 minutes) with the infant to facilitate bonding. 7. Immediately after childbirth in the recovery area, the nurse observes the mother’s partner’s fascination and interest in the new son. This behavior is often termed: a. Attachment b. Engrossment c. Bonding d. Temperament 8. After the nurse provides instructions to a postpartum woman about postpartum

blues, which statement would indicate understanding of it? I will a. “Need to take medication daily to treat the anxiety and sadness.” b. “Call the OB support line only if I start to hear voices.” c. “Contact my doctor if I become dizzy and fell nauseated.” d. “Feel like laughing one minute and crying the next minute.”

CRITICAL THINKING EXERCISE 1. A new nurse assigned to the postpartum mother–baby unit makes a comment to the oncoming shift that, a 25-year-old primipara, seems lazy and shows no initiative in taking care of herself or her baby. The nurse reported that this new mother talks excessively about her labor and birth experience and seems preoccupied with herself and her needs, not her newborn’s care. She wonders if something is wrong with this mother because she seems so self-centered and has to be directed to do everything. a. Is there something “wrong” with Ms. Griffin’s behavior? Why or why not? b. What maternal role phase is being described by the new nurse? c. What role can the nurse play to support the mother through this phase? 2. A primipara gave birth to a healthy baby boy yesterday. Her partner seemed elated at the birth, calling their friends and family on his cell phone minutes after the birth. He passed out cigars and praised his wife for her efforts. Today, when the nurse walked into their room, her partner seemed very anxious around his new son and called for the nurse whenever the baby cried or needed a diaper change. He seemed standoffish when asked to hold his son, and he spent time talking to other fathers in the waiting room, leaving his wife alone in the room. a. Would you consider Mr. Lenhart’s paternal behavior to be normal at this time? b. What might Mr. Lenhart be feeling at this time? c. How can the nurse help this new father adjust to his new role?

STUDY ACTIVITIES 1. Find an Internet resource that discusses general postpartum care for new

mothers who might have questions after discharge. Evaluate the web site’s information as to how credible, accurate, and current the information is. 2. Prepare a teaching plan for new mothers, outlining the various physiologic changes that will take place after discharge. 3. The term that describes the return of the uterus to its prepregnant state is _____________. 4. A deviated fundus to the right side of the abdomen would indicate a _____________.

BRINGING IT ALL TOGETHER: CASE STUDY A 29-year-old married Latina mother of four children lived with her migrant husband and his parents in a small rural border town. She had given birth to her fourth child 7 weeks ago. She now had four children in the past four years. Her pregnancy, labor, and birth had been uneventful, and an untrained neighbor woman helped conduct the home birth. Because pregnancy was viewed as a normal occurrence that did not require any medical attention, she did not receive any prenatal care for any of her four pregnancies. For the first month after birth, she felt normal, but then began to exhibit restless and anxious behavior. She became isolated from her family, stopped speaking to them, and ceased to care for her newborn or other children. Her family wondered about her isolation, but seemed indifferent to her condition, as they were all busy with their own lives. One day when all of her family members and her children had gone to work in the fields, she ended her life. Go to

to find questions to consider about this case.

16 Nursing Management During the Postpartum Period

KEY TERMS attachment bonding en face position pelvic floor exercises peribottle postpartum blues sitz bath

Learning Objectives Upon completion of the chapter, you will be able to: 1. Characterize the normal physiologic and psychological adaptations to the postpartum period. 2. Determine the parameters that need to be assessed during the postpartum period. 3. Compare and contrast bonding to the attachment process. 4. Select behaviors that enhance or inhibit the attachment process. 5. Outline nursing management for the woman and her family during the postpartum period. 6. Examine the role of the nurse in promoting successful breast-feeding. 7. Plan areas of health education needed for discharge planning, home care, and follow-up. A 24-year-old Muslim primipara has just been admitted to the postpartum unit. Her husband sits at the bedside, but doesn’t seem to provide her any physical or emotional support after her lengthy labor and difficult birth.

Words of Wisdom Parenting is an intimate, interactive, continuous, lifelong process.

INTRODUCTION The postpartum period is a time of major adjustments and adaptations not just for the mother, but for all members of the family. It is during this time that parenting starts and a relationship with the newborn begins. A positive, loving relationship between parents and their newborn promotes the emotional wellbeing of all. This relationship endures and has profound effects on the child’s growth and development.

Take Note! Parenting is a skill that is often learned by trial and error, with varying degrees of success. Successful parenting, a continuous and complex interactive process, requires the parents to learn new skills and to integrate the new member into the family. Once the infant is born, each system in the mother’s body takes several weeks to return to its nonpregnant state. The physiologic changes in women during the postpartum period are dramatic. Nurses should be aware of these changes and should be able to make observations and assessments to validate normal occurrences and detect any deviations. This chapter describes the nursing management of the woman and her family during the postpartum period. (See Chapter 21 for a detailed discussion of the postpartum care of the woman undergoing a surgical birth.) Nursing management during the postpartum period focuses on assessing the woman’s ability to adapt to the physiologic and psychological changes occurring at this time (see Chapter 15 for a detailed discussion of these adaptations). The chapter outlines physical assessment parameters for new mothers and newborns. It also focuses on bonding and attachment behaviors; nurses need to be aware of these behaviors so they can perform appropriate interventions. Family members are also assessed to determine how well they are making the transition to this new stage. Based on assessment findings, the nurse plans and implements care to address the family’s needs. Steps to address physiologic needs such as comfort, self-care,

nutrition, and contraception are described. Ways to help the woman and her family adapt to the birth of the newborn are also discussed (Fig. 16.1). Because of today’s shortened lengths of stay, the nurse may be able to focus only on priority needs and may need to arrange for follow-up in the home to ensure that all the family’s needs are met.

SOCIAL SUPPORT AND CULTURAL CONSIDERATIONS In addition to physical assessment and care of the woman in the postpartum period, strong social support is vital to help her integrate the baby into the family. A key to providing effective postpartum care is to understand the woman in her social and cultural context so that all care provided is culturally competent and sensitive. In today’s mobile society, extended families may live far away and may be unable to help care for the new family. As a result, many new parents turn to health care providers for information as well as physical and emotional support during this adjustment period. Nurses can be an invaluable resource by serving as mentors, teaching about self-care measures and baby care basics, and providing emotional support. Nurses can “mother” the new mother by offering physical care, emotional support, information, and practical help. The nurse’s support and care through this critical time can increase the new parents’ confidence, giving them a sense of accomplishment in their parenting skills. One important intervention during the postpartum period is promotion of breastfeeding. Healthy People 2020 includes breast-feeding as a goal for maternal, infant, and child health (U.S. Department of Health and Human Resources [USDHHS], 2010).

FIGURE 16.1 Parents and grandmother interacting with the newborn.

As in all nursing care, nurses should provide culturally competent care during

the postpartum period. The nurse should engage in ongoing cultural selfassessment and overcome any stereotypes that perpetuate prejudice or discrimination against any cultural group (Bowers & Ceballos, 2015). Providing culturally competent nursing care during the postpartum period requires time, open-mindedness, and patience. The global migration of diverse populations presents nurses with the challenge of providing care to unprecedented numbers of clients and their families with health care beliefs and practices that differ from their own. Sensitivity cannot be assumed; it needs to be nurtured and developed. The skill set needed by nurses to provide culturally competent care to postpartum clients and their families include understanding their beliefs, experiences, and family environment; facilitating their language through appropriate use of interpreters so that the information provided can be understood; and compassionately respecting clients and their human rights. The Chinese culture values traditions and the involvement of elders in the extended family. Some Chinese women living in the United States practice transnational parenting, a process of sending their American-born child to China to be raised by the extended family there. This obviously has implications for breast-feeding success among these mothers (Lee & Brann, 2015). To promote positive outcomes, the nurse should be sensitive to the woman’s and family’s culture, religion, and ethnic influences (see “Providing Optimal Cultural Care” in the Nursing Interventions section).

HEALTHY PEOPLE 2020 • 16.1

Remember the couple introduced at the beginning of the chapter? When the postpartum nurse comes to examine Raina, her husband quickly leaves the

room and returns a short time later after the examination is complete. How do you interpret his behavior toward his wife? What might you communicate to this couple?

NURSING ASSESSMENT IN THE POSTPARTUM PERIOD Many adaptations and adjustments must be made to accommodate the new family member. The nurse’s focus is on assistance for families to maximize their adjustment, surveillance for maladaptation, and education, consultation, collaboration as needed. Comprehensive nursing assessment begins within an hour after the woman gives birth and continues through discharge.

Take Note! Nurses need a firm grasp of normal findings to be able to recognize abnormal findings and intervene appropriately. This postpartum assessment includes vital signs and physical and psychosocial assessments. It also includes assessing the parents and other family members, such as siblings and grandparents, for attachment and bonding with the newborn. Although the exact protocol may vary among facilities, postpartum assessment typically is performed as follows: • During the first hour: every 15 minutes • During the second hour: every 30 minutes • During the first 24 hours: every 4 hours • After 24 hours: every 8 hours (Jordan et al., 2014; Mattson & Smith, 2016). During each assessment, keep in mind risk factors that may lead to complications, such as infection or hemorrhage, during the recovery period (Box 16.1). Early identification is critical to ensure prompt intervention. The postpartum period is a time of transition for women. The end of the pregnancy and childbirth initiates physiologic changes as many body systems return to their nonpregnant state. Nurses need to be aware of the normal physiologic and psychological changes that take place in clients’ bodies and minds in order to provide comprehensive care during the postpartum period. In addition to client and family teaching, one of the most significant responsibilities

of the postpartum nurse is to recognize potential complications after childbirth. As with any assessment, always review the woman’s medical record for information about her pregnancy, labor, and birth. Note any preexisting conditions, any complications that occurred during pregnancy, labor, birth, and immediately afterward, and any treatments provided. Postpartum assessment of the mother typically includes vital signs, pain level, epidural site inspection for infection, and a systematic head-to-toe review of body systems. The acronym BUBBLE-EEE—breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status— can be used as a guide for this head-to-toe review (Cunningham et al., 2014).

BOX 16.1 FACTORS INCREASING A WOMAN’S RISK FOR POSTPARTUM COMPLICATIONS

Risk Factors for Postpartum Infection • Operative procedure (forceps, cesarean birth, vacuum extraction) • History of diabetes, including gestational-onset diabetes • Prolonged labor (more than 24 hours) • Use of indwelling urinary catheter • Anemia (hemoglobin < 10.5 mg/dL) • Multiple vaginal examinations during labor • Prolonged rupture of membranes (>24 hours) • Manual extraction of placenta • Compromised immune system (HIV positive)

Risk Factors for Postpartum Hemorrhage • Precipitous labor (less than 3 hours) • Uterine atony • Placenta previa or abruptio placenta • Labor induction or augmentation • Operative procedures (vacuum extraction, forceps, cesarean birth) • Retained placental fragments • Prolonged third stage of labor (more than 30 minutes) • Multiparity, more than three births closely spaced • Uterine over distention (large infant, twins, hydramnios)

While assessing the woman and her family during the postpartum period, be alert for danger signs (Box 16.2). Notify the primary health care provider immediately if any are noted.

Vital Signs Assessment Obtain vital signs and compare them with the previous values, noting and reporting any deviations. Vital sign changes can be an early indicator of complications.

BOX 16.2 POSTPARTUM DANGER SIGNS • Fever more than 100.4° F (38° C) • Foul-smelling lochia or an unexpected change in color or amount • Large blood clots, or bleeding that saturates a peripad in an hour • Severe headaches or blurred vision • Visual changes, such as blurred vision or spots, or headaches • Calf pain with dorsiflexion of the foot • Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites • Dysuria, burning, or incomplete emptying of the bladder • Shortness of breath or difficulty breathing without exertion • Depression or extreme mood swings

Temperature Use a consistent measurement technique (oral, axillary, or tympanic) to get the most accurate readings. Typically, the new mother’s temperature during the first 24 hours postpartum is within the normal range or a low-grade elevation. Some women experience a slight fever, up to 100.4° F (38° C), during the first 24 hours. This elevation may be the result of dehydration because of fluid loss during labor. Temperature should be normal after 24 hours with replacement of fluids lost during labor and birth (Green, 2016). A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. An elevated temperature can identify maternal sepsis, which results in significant maternal morbidity and mortality worldwide. To improve the outcome, it is essential that nurses be vigilant in obtaining accurate values and monitoring their client’s temperature.

Pulse Pulse rates of 60 to 80 beats per minute (bpm) at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia. During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart. After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return now. The elevated stroke volume leads to a decreased heart rate (Creasy et al., 2014). Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Any pulse rate higher than 100 bpm warrants further investigation to rule out complications.

Respirations Respiratory rates in the postpartum woman should be within the normal range of 12 to 20 bpm at rest. Pulmonary function typically returns to the prepregnant state after childbirth when the diaphragm descends and the organs revert to their normal positions. Any change in respiratory rate out of the normal range might indicate pulmonary edema, atelectasis, a side effect of epidural anesthesia, or pulmonary embolism and must be reported. Lungs should be clear on auscultation.

Blood Pressure Assess the woman’s blood pressure and compare it with her usual range. Report any deviation from this range. Immediately after childbirth, the blood pressure should remain the same as during labor. An increase in blood pressure could indicate gestational hypertension, whereas a decrease could indicate shock or orthostatic hypotension or dehydration, a side effect of epidural anesthesia. Blood pressure readings should not be higher than 140/90 mm Hg or lower than 85/60 mmHg (King et al., 2015). Blood pressure also may vary based on the woman’s position, so assess blood pressure with the woman in the same position every time. Be alert for orthostatic hypotension, which can occur when the woman moves rapidly from a lying or sitting position to a standing one.

Pain Pain, the fifth vital sign, is assessed along with the other four parameters.

Question the woman about the type of pain and its location and severity. Have the woman rate the pain using a numeric scale from 0 to 10 points. Nursing care should focus on providing comfort measures to ease pain which might include perineal care, clean gown, mouth care, providing warm blankets, ensuring adequate fluid intake to facilitate healing, reposition frequently, and encouraging rest between assessments (Nagtalon-Ramos, 2014). Many postpartum orders will have the nurse premedicate the woman routinely for afterbirth pains rather than wait for her to experience them first. The goal of pain management is to have the woman’s pain scale rating maintained between 0 and 2 points at all times, especially after breast-feeding. This can be accomplished by assessing the woman’s pain level frequently and preventing pain by administering analgesics. If the woman has severe pain in the perineal region despite use of physical comfort measures, check for a hematoma by inspecting and palpating the area. If one is found, notify the health care provider immediately.

Physical Examination Physical examination of the postpartum woman focuses on assessing the breasts, uterus, bladder, bowels, lochia, episiotomy/perineum and epidural site and extremities.

Breasts Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted. Flat or inverted nipples can make breast-feeding challenging for both mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are generally indications that the baby is improperly positioned on the breast. Palpate the breasts lightly to ascertain if they are soft, filling, or engorged, and document your findings. For women who are not breast-feeding, use a gentle, light touch to avoid breast stimulation, which would exacerbate engorgement. Lactogenesis (the onset of milk secretion) is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breast-feeding, the prolactin levels fall and return to normal levels within 2 to 3 weeks. As milk is starting to come in, the breasts become firmer; this is charted as “filling.” Engorged breasts are hard, tender, and taut. Ask the woman if she is having any nipple discomfort. Palpate the breasts for any nodules, masses, or areas of warmth, which may indicate a plugged duct that may progress to mastitis if not treated promptly. Any discharge from the nipple should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white). Over the first week, the breast milk matures and contains all necessary nutrients in the neonatal period. The breast milk continues to change throughout the period of breast-feeding to meet the changing demands of the growing infant.

Uterus Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. If possible, have the woman empty her bladder before assessing the fundus and auscultate her bowel sounds prior to uterine palpation. If the client has had a cesarean birth and has a patient-controlled anesthesia (PCA) pump,

instruct her to self-medicate prior to fundal assessment to decrease her discomfort. Using a two-handed approach with the woman in the supine position with her knees flexed slightly and the bed in a flat position or as low as possible, palpate the abdomen gently, feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it (Fig. 16.2). The fundus should be midline and should feel firm. A boggy or relaxed uterus is a sign of uterine atony (loss of muscle tone in the uterus). This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Either situation predisposes the woman to hemorrhage. Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus (1 fingerbreadth is approximately equal to 1 cm). One to 2 hours after birth, the fundus typically is between the umbilicus and the symphysis pubis. Approximately 6 to 12 hours after birth, the fundus usually is at the level of the umbilicus. If the fundal height is above the umbilicus, which would be an abnormal finding, investigate this immediately to prevent excessive bleeding. Frequently the woman’s bladder is full, thus displacing the uterus up and to either side of the midline. Ask the woman to empty her bladder and reassess the uterus again.

FIGURE 16.2 Palpating the fundus.

Normally, the fundus progresses downward at a rate of one fingerbreadth (or 1 cm) per day after childbirth and should be nonpalpable by 10 to 14 days postpartum. By day 14, the uterus has descended below the rim of the symphysis pubis and is no longer palpable (Cunningham et al., 2014). On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as u/1. Similarly, on the second postpartum day, the fundus would be 2 cm below the umbilicus and should be recorded as u/2, and so on. Health care agencies differ according to how fundal heights are charted, so follow their protocols for this. If the fundus is not firm, gently massage the uterus using a circular motion until it becomes firm.

Bladder Considerable diuresis—as much as 3,000 mL/day—begins within 12 hours after childbirth and continues for several days. A single voiding may be 500 mL or more. By 21 days postpartum, the diuresis is usually complete (Jordan et al., 2014). However, many postpartum women do not sense the need to void even if their bladder is full. In this situation the bladder can become distended and

displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to excessive bleeding. Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections. It is imperative that nurses monitor clients for signs of urinary tract infections, including fever, urinary frequency and/or urgency, difficult or painful urination, and tenderness over the costovertebral angle (Wilson et al., 2015). Women who received regional anesthesia during labor are at risk for urinary tract infections due to continuous urinary catheterization to prevent urinary retention during labor, which is thought to delay fetal descent. They also experience difficulty voiding and loss of sensation and must wait until it returns to feel a full bladder which might be several hours after childbirth. Assess for voiding problems by asking the woman the following questions: • Have you (voided, urinated, gone to the bathroom) yet? • Have you noticed any burning or discomfort with urination? • Do you have any difficulty passing your urine? • Do you feel that your bladder is empty when you finish urinating? • Do you have any signs of infection such as urgency, frequency, or pain? • Are you able to control the flow of urine by squeezing your muscles? • Have you noticed any leakage of urine when you cough, laugh, or sneeze? Assess the bladder for distention and adequate emptying after efforts to void. Palpate the area over the symphysis pubis. If empty, the bladder is not palpable. Palpation of a rounded mass suggests bladder distention. Also percuss the area: a full bladder is dull to percussion. If the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding.

Take Note! Note the location and condition of the fundus; a full bladder tends to displace the uterus up and to the right. After the woman voids, palpate and percuss the area again to determine adequate emptying of the bladder. If the bladder remains distended, the woman may be retaining urine in her bladder, and measures to initiate voiding should be

instituted. Be alert for signs of infection, including infrequent or insufficient voiding (less than 200 mL), discomfort, burning, urgency, or foul-smelling urine (Mattson & Smith, 2016). Document all urine output.

Bowels Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth (Verghese, Futaba, & Latthe, 2015). Often women are hesitant to have a bowel movement due to pain in the perineal area resulting from an episiotomy, lacerations, or hemorrhoids. Some are fearful that they may “rip their stitches” should they strain. Nurses should reassure their clients that stool softeners and/or laxatives to treat constipation have been prescribed for them to reduce discomfort. Inspect the woman’s abdomen for distention, auscultate for bowel sounds in all four quadrants prior to palpating the uterine fundus, and palpate for tenderness. The abdomen typically is soft, nontender, and nondistended. Bowel sounds are present in all four quadrants. Ask the woman if she has had a bowel movement or has passed gas since giving birth, because constipation is a common problem during the postpartum period and many women do not offer this information unless asked about it. Normal assessment findings are active bowel sounds, passing gas, and a nondistended abdomen.

Lochia Assess lochia in terms of amount, color, odor, and change with activity and time. To assess how much a woman is bleeding, ask her how many perineal pads she has used in the past 1 to 2 hours and how much drainage was on each pad. For example, did she saturate the pad completely, or was only half of the pad covered with drainage? Ask about the color of the drainage, odor, and the presence of any clots. Lochia has a definite musky scent, with an odor similar to that of menstrual flow without any large clots (fist size). Foul-smelling lochia suggests an infection, and large clots suggest poor uterine involution, necessitating additional intervention. To determine the amount of lochia, observe the amount of lochia saturation on the perineal pad and relate it to time (Fig. 16.3). Also, take into consideration the specific type of peripad used, because some are more absorbent than others.

Lochia flow will increase when the woman gets out of bed (lochia pools in the vagina and the uterus while she is lying down) and when she breast-feeds (oxytocin release causes uterine contractions). A woman who saturates a perineal pad within 30 to 60 minutes is bleeding much more than one who saturates a pad in 2 hours.

FIGURE 16.3 Assessing lochia.

Typically, the amount of lochia is described as follows: • Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss • Light or small: an approximately 4-inch stain or a 10- to 25-mL loss • Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL • Large or heavy: a pad is saturated within 1 hour after changing it (Bope & Kellerman, 2015) The total volume of lochial discharge varies in women based on their parity, but the amount decreases daily. Check under the woman, by turning her to either side, to make sure additional blood is not hidden and not absorbed on her perineal pad. This also a good time to assess for the presence and condition of hemorrhoids since the nurse is visually inspecting the perineum. Report any abnormal findings, such as heavy, bright-red lochia with large tissue fragments or a foul odor. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood.

Document all findings. Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, but stages and color changes remain the same. Although the woman’s abdomen will be tender after surgery, the nurse must palpate the fundus and assess the lochia to make sure they are within the normal range and that there is no excessive bleeding. Anticipatory guidance to give the woman at discharge should include information about lochia and the expected changes. Urge the woman to notify her health care provider if lochia rubra returns after the serosa and alba transitions have taken place. This is abnormal and may indicate subinvolution or that the woman is too active and needs to rest more. Lochia is an excellent medium for bacterial growth. Explain to the woman that frequent changing of perineal pads, continued use of her peribottle for rinsing her perineal area, and hand hygiene before and after pad changes are important infection control measures.

Episiotomy/Perineum and Epidural Site If the woman has an episiotomy, which is not routinely done currently, to assess the episiotomy and perineal area, position the woman on her side with her top leg flexed upward at the knee and drawn up toward her waist. If necessary, use a penlight to provide adequate lighting during the assessment. Wearing gloves and standing at the woman’s side with her back to you, gently lift the upper buttock to expose the perineum and anus (Fig. 16.4). Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas. Assess for hemorrhoids and their condition.

FIGURE 16.4 Inspecting the perineum.

During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, discharge, or edema. The majority of healing takes place within the first 2 weeks, but it may take 4 to 6 months for the episiotomy to heal completely (King et al., 2015). Lacerations to the perineal area sustained during the birthing process that were identified and repaired also need to be assessed to determine their healing status. Lacerations are classified based on their severity and tissue involvement: • First-degree laceration: involves only skin and superficial structures above muscle • Second-degree laceration: extends through perineal muscles • Third-degree laceration: extends through the anal sphincter muscle • Fourth-degree laceration: continues through anterior rectal wall Assess the episiotomy and any lacerations at least every 8 hours to detect hematomas or signs of infection. Large areas of swollen, bluish skin with complaints of severe pain in the perineal area indicate pelvic or vulvar hematomas. Redness, swelling, increasing discomfort, or purulent drainage may indicate infection. Both findings need to be reported immediately. A white line running the length of the episiotomy is a sign of infection, as is swelling or discharge. Severe, intractable pain, perineal discoloration, and ecchymosis indicate a perineal hematoma, a potentially dangerous condition. Report any unusual findings. Ice can be applied to relieve discomfort and reduce edema; sitz baths also can promote comfort and perineal healing (see “Promoting Comfort” in the Nursing Interventions section). If the woman has had an epidural during her labor, assessment of the epidural wound site is important as well as checking for any side effects of the medication injected such as itching, nausea and vomiting, or urinary retention. Visual inspection of the epidural site and an accurate documentation of intake and output are essential.

Extremities Pregnancy is associated with an increased risk of venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. During

pregnancy, the state of hypercoagulability protects the mother against excessive blood loss during childbirth and placental separation. However, this hypercoagulable state can increase the risk of thromboembolic disorders during pregnancy and postpartum. Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of the gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during the birthing process). All of these factors increase the risk of clot formation and having it travel to the lungs. While inspecting the woman’s extremities, also determine the degree of sensory and motor function return (recovery from anesthesia) by asking the woman if she feels sensation at various areas the nurse touches and also by observing her ambulation stability.

Take Note! Pulmonary embolism occurs in up to 3 per 1000 births and is a major cause of maternal mortality (Kim et al., 2015). Pulmonary emboli typically result from dislodged deep vein thrombi in the lower extremities. Risk factors associated with thromboembolic conditions include: • Anemia • Diabetes mellitus • Cigarette smoking • Obesity • Preeclampsia • Hypertension • Severe varicose veins • Pregnancy • Multiple pregnancies • Cardiovascular disease • Sickle cell disease • Postpartum hemorrhage

• Oral contraceptive use • Cesarean birth • Severe infection • Previous thromboembolic disease • Multiparity • Bed rest or immobility for 4 days or more • Advanced maternal age > 35 years (Kline & Kabrhel, 2015) Because of the subtle presentation of thromboembolic disorders, the physical examination may not be enough to detect them. An accurate diagnosis of pulmonary embolism is needed because it requires (1) prolonged therapy (≤9 months of heparin during pregnancy), (2) prophylaxis during future pregnancies, and (3) avoidance of oral contraceptive pills. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation of the leg. Edema in the affected leg (typically the left), along with warmth and tenderness, and a low-grade fever may also be noted. A duplex ultrasound (two-dimensional ultrasound and Doppler ultrasound that compresses the vein to assess for changes in venous flow) in conjunction with the physical findings frequently is needed for a conclusive diagnosis (Sucker & Zotz, 2015). Women with an increased risk for this condition during the postpartum period should wear antiembolism stockings or use sequential compression devices to reduce the risk of venous stasis by preventing blood from pooling in the calves of the legs. Encouraging the client to ambulate after childbirth reduces the incidence of thrombophlebitis.

Psychosocial Assessment Psychosocial assessment of the postpartum woman focuses on emotional status and bonding and attachment.

Emotional Status Assess the woman’s emotional status by observing how she interacts with her family, her level of independence, energy levels, eye contact with her infant (within a cultural context), posture and comfort level while holding the newborn, and sleep and rest patterns. Be alert for mood swings, irritability, or crying episodes. Remember Raina and her “quiet” husband, the Muslim couple? The postpartum nurse informs Raina that her doctor, Nancy Schultz, has been called away for emergency surgery and won’t be available the rest of the day. The nurse explains that Dr. Robert Nappo will be making rounds for her. Raina and her husband become upset. Why? Is culturally competent care being provided to this couple?

Bonding and Attachment Nurses can be instrumental in promoting attachment by assessing attachment behaviors (positive and negative) and intervening appropriately if needed. Nurses must be able to identify any family discord that might interfere with the attachment process. Remember, however, that mothers from different cultures may behave differently from what is expected in your own culture. For example, Native American mothers tend to handle their newborns less often and use cradle boards to carry them. Native American mothers and many Asian American mothers delay breast-feeding until their milk comes in, because colostrum is considered harmful for the newborn (Bowers & Ceballos, 2015). Do not assume that different behavior is wrong. Meeting the newborn for the first time after birth can be an exhilarating experience for parents. Although the mother has spent many hours dreaming of her unborn and how he or she will look, it is not until after birth that they meet face to face. They both need to get to know one another and to develop feelings

for one another. Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth. Bonding is really a continuation of the relationship that began during pregnancy (Sears & Sears, 2015a). It is affected by a multitude of factors, including the parent’s socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending her child. The infant’s responses to this, such as body and eye movements, are a necessary part of the process. During this initial period, the infant is in a quiet, alert state, looking directly at the holder.

Take Note! The length of time necessary for bonding depends on the health of the infant and mother, as well as the circumstances surrounding the labor and birth (TesterJones et al., 2015). Attachment is the development of strong affection between an infant and a significant other (mother, father, sibling, and caretaker). This attachment is reciprocal; both the significant other and the newborn exhibit attachment behaviors. The attachment relationship formed between the infant and primary caregiver influences the child’s view of the world and future relationships (Sette, Coppola, & Cassibba, 2015). This tie between two people is psychological rather than biologic, and it does not occur overnight. The process of attachment follows a progressive or developmental course that changes over time. Attachment is an individualized and multifactorial process that differs based on the health of the infant, the mother, environmental circumstances, and the quality of care the infant receives. The newborn responds to the significant other by cooing, grasping, smiling, and crying. Nurses can assess for attachment behaviors by observing the interaction between the newborn and the person holding him or her (Mattson & Smith, 2016). It occurs through mutually satisfying experiences. Maternal attachment begins during pregnancy as the result of fetal movement and maternal fantasies about the infant and continues through the birth and

postpartum periods. Attachment behaviors include seeking, physical caretaking behaviors, emotional attentiveness to infant’s needs, staying close to, touching, kissing, cuddling, choosing the en face (face-to-face) position while holding or feeding the newborn, expressing pride in the newborn and exchanging gratifying experiences with the infant (McComish, 2015). In a high-risk pregnancy, the attachment process may be complicated by premature birth (lack of time to develop a relationship with the unborn baby) and by parental stress due to the fetal and/or maternal vulnerability. Bonding is a vital component of the attachment process and is necessary in establishing parent–infant attachment and a healthy, loving relationship. During this early period of acquaintance, mothers touch their infants in a very characteristic manner. Mothers visually and physically “explore” their infants, initially using their fingertips on the infant’s face and extremities and progressing to massaging and stroking the infant with their fingers. This is followed by palm contact on the trunk. Eventually, mothers draw their infant toward them and hold the infant (Fig. 16.5). Generally, research on attachment has found that the process is similar for partners as for mothers, but the pace may be different. Like mothers, partners manifest attachment behaviors during pregnancy. Indeed, Baltes et al. (2014) found that the best predictors of early postnatal attachment for fathers or significant others were those who viewed the paternal caregiving role as important and also had greater marital quality. Higher levels of paternal sensitivity were associated with better infant–father attachment. Becoming a father or significant partner requires the person to build on the experiences he/she has had throughout childhood and adolescence. Fathers or significant other partners develop an emotional tie with their infants in a variety of ways. They seek and maintain closeness with the infant and can recognize characteristics of the infant. Another study further described paternal attachment as a permanent, cyclical concept characterized by changes in response to the child’s developmental stage. When children have a secure, supportive, and sensitive relationship with their fathers or mother’s significant other, they are generally better adjusted than those that have a nonsupportive relationship (Lickenbrock & Braungart-Rieker, 2015).

FIGURE 16.5 En face position.

Attachment is a process; it does not occur instantaneously, even though many parents believe in a romanticized version of attachment, which happens right after birth. A delay in the attachment process can occur if a mother’s physical and emotional states are adversely affected by exhaustion, pain, and the absence of a support system; if she has an infant in NICU and is separated from it; or had a traumatic birth experience, anesthesia, or an unwanted outcome, such as an ill infant (Lee et al., 2014).

Take Note! Touch is a basic instinctual interaction between a parent and his or her infant and has a vital role in the infant’s early development. Parents provide a variety of tactile stimulation while addressing their infant’s daily care routines (Hugill, 2015). The developmental task for the infant is learning to differentiate between trust and mistrust. If the mother or caretaker is consistently responsive to the infant’s care, meeting the baby’s physical and psychological needs, the infant will likely learn to trust the caretaker, view the world as a safe place, and grow up to be secure, self-reliant, trusting, cooperative, and helpful. However, if the infant’s needs are not met, the child is more likely to face developmental delays, neglect,

and child abuse (Klebanov & Travis, 2015). “Becoming” a parent may take 4 to 6 months. The transition to parenthood, according to Mercer (2006), involves four stages: 1. Commitment, attachment, and preparation for an infant during pregnancy 2. Acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth 3. Moving toward a new normal routine in the first 4 months after birth 4. Achievement of a parenthood role around 4 months The stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners (Mercer, 2006). FACTORS AFFECTING ATTACHMENT Attachment behaviors are influenced by three major factors: 1. Parents’ background (includes the care that the parents received when growing up, cultural practices, relationship within the family, experience with previous pregnancies and planning and course of events during pregnancy, postpartum depression) 2. Infant (includes the infant’s temperament and health at birth) 3. Care practices (the behaviors of physicians, midwives, nurses, and hospital personnel, care and support during labor, first day of life in separation of mother and infant, and rules of the hospital or birthing center) (Lewis & Rudolph, 2014). Attachment occurs more readily with the infant whose temperament, health, appearance, and gender fit the parent’s expectations. If the infant does not meet these expectations, attachment can be delayed (Lickenbrock & Braungart-Rieker, 2015). Factors associated with the health care facility or birthing unit can also hinder attachment. These include: • Separation of infant and parents immediately after birth and for long periods during the day • Policies that discourage unwrapping and exploring the infant • Intensive care environment, restrictive visiting policies

• Staff indifference or lack of support for parent’s caretaking attempts and abilities Concept Mastery Alert Grief After Delivery of a Child with Special Needs It is important for the mother to visit the child in the special care nursery, but the priority is to assist the mother in dealing with the grief that accompanies giving birth to a child with special needs. The mother must first mourn the loss of the “perfect child.”

CRITICAL ATTRIBUTES OF ATTACHMENT The terms bonding and attachment are often used interchangeably, even though they involve different time frames and interactions. Attachment stages include proximity, reciprocity, and commitment. Proximity refers to the physical and psychological experience of the parents being close to their infant. This attribute has three dimensions: 1. Contact: The sensory experiences of touching, holding, and gazing at the infant are part of proximity-seeking behavior. 2. Emotional state: The emotional state emerges from the affective experience of the new parents toward their infant and their parental role. 3. Individualization: Parents are aware of the need to differentiate the infant’s needs from themselves and to recognize and respond to them appropriately, making the attachment process also, in some way, one of detachment. Reciprocity is the process by which the infant’s abilities and behaviors elicit parental response. Reciprocity is described by two dimensions: complementary behavior and sensitivity. Complementary behavior involves taking turns and stopping when the other is not interested or becomes tired. An infant can coo and stare at the parent to elicit a similar parental response to complement his or her behavior. Parents who are sensitive and responsive to their infant’s cues will promote their development and growth. Parents who become skilled at recognizing the ways their infant communicates will respond appropriately by

smiling, vocalizing, touching, and kissing. Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant’s safety, growth, and development. Parent role exploration is the parents’ ability to find their own way and integrate the parental identity into themselves (Sears & Sears, 2015b). POSITIVE AND NEGATIVE ATTACHMENT BEHAVIORS Positive bonding behaviors include maintaining close physical contact, making eye-to-eye contact, speaking in soft, high-pitched tones, and touching and exploring the infant. Table 16.1 highlights typical positive and negative attachment behaviors.

NURSING INTERVENTIONS In terms of postpartum hospital stays today, “less is more.” If the woman had a vaginal delivery, she may be discharged within 48 hours or sooner. If she had a cesarean birth, she may remain hospitalized for up to 72 hours. This shortened stay leaves little time for nurses to prepare the woman and her family for the many changes that will occur when she returns home (see Nursing Care Plan 16.1). Research shows that mothers feel unprepared, uninformed, and unsupported during the postpartum period as they struggle with physical and emotional issues, infant caregiving, breast-feeding concerns, and lifestyle adjustments (Walker, Murphey, & Nichols, 2015). Nurses need to focus on: pain and discomfort, immunizations, nutrition, activity and exercise, infant care, lactation instruction, discharge teaching, sexuality and contraception, and follow-up with the limited time they have with their clients. Planning home visits to reinforce postpartum instructions may enhance maternal-infant wellness (see Evidence-Based Practice 16.1). TABLE 16.1 Positive and Negative Attachment Behaviors

Take Note!

Always adhere to standard precautions when providing direct care to reduce the risk of disease transmission.

Providing Optimal Cultural Care As the face of America is becoming more diverse, nurses must be prepared to care for childbearing families from various cultures. In many cultures, women and their families are cared for and nurtured by their community for weeks and even months after the birth of a new family member. Overall, the culturally competent care for all childbearing families include understanding of traditional folk beliefs; involvement and support by family members; respect; presence of a significant other; breast-feeding and eating healthy; observing the principles of hot and cold; avoidance of sexual intercourse postnatally; encouragement; empowerment; their spiritual dimensions as important; avoidance of evil spirits; and the hope that nurses will anticipate the needs of the mother and infant (McFarland & Wehbe-Alamah, 2015). Box 16.3 highlights some of the major cultural variants during the postpartum period.

EVIDENCE-BASED PRACTICE 16.1 ENHANCING NEONATAL WELLNESS WITH HOME VISITATION

STUDY According to the AAP, there is sufficient evidence that breast-feeding provides the best nutrition for newborns and should be continued for the first 6 months followed by continued breast-feeding during the first year or more, as solid foods are introduced. The purpose of this study was to measure the effectiveness of home visits by RNs on neonatal wellness as measured by the continuance of breast-feeding at 6 months, reduce readmissions for newborn jaundice and identify any maternal or newborn health issues. The home visits were made on days three and seven after discharge from the hospital. A complete physical assessment on both mother and infant was performed at each home visit.

Findings The study used a longitudinal, mixed method, within-subject design involving 1705 participants. Quantitative data were compared to regional and national benchmarks. Qualitative data from study participant interviews were analyzed to identify common themes. The data indicated the home visits did help mothers to continue to breast-feed longer when compared to the regional and national statistics and the home visits also effectively identified newborn jaundice with a reduction in the average length of stay for infants readmitted in comparison to benchmarks.

Nursing Implications The study’s results reinforce the need for extended breast-feeding support beyond the hospital setting discharge for new mothers to continue to breastfeed longer. New mothers need to have access to community-based interventions after discharge to reinforce their postpartum education. Nurses can be instrumental in making referrals for home visitations to promote the safe transition from the hospital to the home. Adapted from Parker, C., Warmuskerken, G., & Sinclair, L. (2015). Enhancing neonatal wellness with home visitation. Nursing for Women’s Health, 19(1), 36–45.

NURSING CARE PLAN 16.1 Overview of the Postpartum Woman A 26-year-old G2P2, is a client on the mother–baby unit after giving birth to a term 8-lb, 12-oz baby boy yesterday. The night nurse reports that she has an episiotomy, complains of a pain rating of 7 points on a scale of 1 to 10, is having difficulty breast-feeding, and had heavy lochia most of the night. The nurse also reports that the client seems focused on her own needs and not on those of her infant. Assessment this morning reveals the following: B: Breasts are soft with colostrum leaking; nipples cracked U: Uterus is one fingerbreadth below the umbilicus; deviated to right B: Bladder is palpable; client states she hasn’t been up to void yet B: Bowels have not moved; bowel sounds present; passing flatus L: Lochia is moderate; peripad soaked from night accumulation E: Episiotomy site intact; swollen, bruised; hemorrhoids present E: Extremities; no edema over tibia, no warmth or tenderness in calf E: Emotional status is “distressed” as a result of discomfort and fatigue NURSING DIAGNOSIS: Impaired tissue integrity related to episiotomy Outcome Identification and Evaluation The client will remain free of infection, without any signs and symptoms of infection, and exhibit evidence of progressive healing as demonstrated by clean, dry, decreased/absent edema, and an intact episiotomy site. Interventions: Promoting Tissue Integrity • Monitor episiotomy site for redness, edema, warmth or discharge to identify infection. • Assess vital signs at least every 4 hours to identify changes suggesting infection. • Apply ice pack to episiotomy site to reduce swelling. • Instruct client on use of sitz bath to promote healing, hygiene, and comfort. • Encourage frequent perineal care and peripad changes to prevent infection. • Recommend ambulation to improve circulation and promote healing. • Instruct client on positioning to relieve pressure on perineal area.

• Demonstrate use of anesthetic sprays to numb perineal area. NURSING DIAGNOSIS: Pain related to episiotomy, sore nipples, and hemorrhoids Outcome Identification and Evaluation The client will experience a decrease in pain as evidenced by reporting that her pain has diminished to a tolerable level and rating it as 2 points or less. Interventions: Providing Pain Relief • Thoroughly inspect perineum to rule out hematoma as cause of pain. • Administer analgesic medication as ordered as needed to promote comfort. • Carry out comfort measures to episiotomy as outlined earlier to reduce pain. • Explain discomforts and reassure the client that they are time limited to assist in coping with pain. • Apply Tucks® to swollen hemorrhoids to induce shrinkage and reduce pain. • Suggest frequent use of sitz bath to reduce hemorrhoid pain. • Administer stool softener and laxative to prevent straining with first bowel movement. • Observe positioning and latching-on technique while breast-feeding. Offer suggestions based on observations to correct positioning/latching on to minimize trauma to the breast. • Suggest air-drying of nipples after breast-feeding and use of plain water to prevent nipple cracking. • Teach relaxation techniques when breast-feeding to reduce anxiety and discomfort. NURSING DIAGNOSIS: Risk for ineffective coping related to mood alteration and pain Outcome Identification and Evaluation The client will cope with mood alterations, as evidenced by positive statements about newborn and participation in newborn care. Interventions: Promoting Effective Coping • Provide a supportive, nurturing environment and encourage the mother to vent her feelings and frustrations to relieve anxiety.

• Provide opportunities for the mother to rest and sleep to combat fatigue. • Encourage the mother to eat a well-balanced diet to increase her energy level. • Provide reassurance and explanations that mood alterations are common after birth secondary to waning hormones after pregnancy to increase the mother’s knowledge. • Allow the mother relief from newborn care to afford opportunity for selfcare. • Discuss with partner expected behavior from mother and how additional support and help are needed during this stressful time to promote partner’s participation in care. • Make appropriate community referrals for mother–infant support to ensure continuity of care. • Encourage frequent skin-to-skin contact and closeness between mother and infant to facilitate bonding and attachment behaviors. • Encourage client to participate in infant care and provide instructions as needed to foster a sense of independence and self-esteem. • Offer praise and reinforcement of positive mother–infant interactions to enhance self-confidence in care. Nurses need to remember that childbearing practices and beliefs vary from culture to culture. To provide appropriate nursing care, the nurse should determine the client’s preferences before intervening. Cultural practices may include dietary restrictions, certain clothes, taboos, activities for maintaining mental health, and the use of silence, prayer, or meditation. Restoring health may involve taking folk medicines or conferring with a tribal healer. A language barrier might interfere with communication between the woman and health providers, followed by health care provider’s lack of cultural sensitivity, leading to a woman’s reluctance in using health services (Santiago & Figueiredo, 2015). Providing culturally diverse care within our global community is challenging for all nurses, because they must remember that one’s culture cannot be easily summarized in a reference book, but must be viewed through one’s own life experiences. The Muslim woman and her husband are upset at the thought of having a

male doctor care for her because Muslim women are very modest and prefer having a same-sex care provider. What should the nurse do in this situation?

BOX 16.3 CULTURAL INFLUENCES DURING THE POSTPARTUM PERIOD

African American • Mother may share care of the infant with extended family members. • Experiences of older women within the family influence infant care. • Mothers may protect their newborns from strangers for several weeks. • Mothers may not bathe their newborns for the first week. Oils are applied to skin and hair to prevent dryness and cradle cap. • Silver dollars may be taped over the infant’s umbilicus in an attempt to flatten the slightly protruding umbilical stump. • Sleeping with parents is a common practice.

Amish • Women consider childbearing their primary role in society. • They generally oppose birth control. • Pregnancy and childbirth are considered a private matter; they may conceal it from public knowledge. • Women typically do not respond favorably when hurried to complete a selfcare task. Nurses need to take cues from women indicating their readiness to complete morning self-care activities.

Appalachian • Infant colic is treated by passing the newborn through a leather horse’s collar or administering weak catnip tea. • An asafetida bag (a gum resin with a strong odor) is tied around the infant’s neck to ward off disease. • Women may avoid eye contact with nurses and health care providers. • Women typically avoid asking questions even though they do not understand directions. • The grandmother may rear the infant for the mother.

Filipino American • Grandparents often assist in the care of their grandchildren. • Breast-feeding is encouraged, and some mothers breast-feed their children for up to 2 years. • Women have difficulty discussing birth control and sexual matters. • Strong religious beliefs prevail and bedside prayer is common. • Families are very close-knit and numerous visitors can be expected at the hospital after childbirth.

Japanese American • Cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. • Newborns routinely are not taken outside the home because it is believed that they should not be exposed to outside or cold air. Infants should be kept in a quiet, clean, warm place for the first month of life. • Breast-feeding is the primary method of feeding. • Many women stay in their parents’ home for 1 to 2 months after birth. • Bathing the infant can be the center of family activity at home.

Mexican American • The newborn’s grandmother lives with the mother for several weeks after birth to help with housekeeping and child care. • Most women will breast-feed for more than 1 year. The infant is carried in a rebozo (shawl) that allows easy access for breast-feeding. • Women may avoid eye contact and may not feel comfortable being touched by a stranger. Nurses need to respect this feeling. • Some women may bring religious icons to the hospital and may want to display them in their room.

Muslim • Modesty is a primary concern; nurses need to protect the client’s modesty. • Muslims are not permitted to eat pork; check all food items before serving. • Muslims prefer a same-sex health care provider; male–female touching is prohibited except in an emergency situation. • A Muslim woman stays in the house for 40 days after birth, being cared for by the female members of her family. • Most women will breast-feed, but religious events call for periods of fasting, which may increase the risk of dehydration or malnutrition. • Women are exempt from obligatory five-times-daily prayers as long as lochia is present. • Extended family is likely to be present throughout much of the woman’s hospital stay. They will need an empty room to perform their prayers without having to leave the hospital.

Native American • Women are secretive about pregnancies and do not reveal them early. • Touching is not a typical female behavior and eye contact is brief. • They resent being hurried and need time for sitting and talking. • Most mothers breast-feed and practice birth control. Adapted from Bowers, P., & Caballos, K. (2015). Cultural perspectives in childbearing. Retrieved from http://ce.nurse.com/ce263-60/Cultural-Perspectives-in-Childbearing; Dayer-Berenson, L. (2014). Cultural competencies of nurses: Impact on health and illness (2nd ed.). Burlington, MA: Jones & Bartlett Learning; and Andrews, M. M., & Boyle, J. S. (2012). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Wolters Kluwer Health.

Promoting Comfort The postpartum woman may have discomfort and pain from a variety of sources, such as an episiotomy, perineal lacerations, backache as a result of the epidural, pain from a full bladder, an edematous perineum, inflamed hemorrhoids, engorged breasts, afterbirth pains secondary to uterine contractions in breastfeeding and multiparous mothers, and sore nipples if breast-feeding. Relieving the underlying problem is the first step in pain management. Most practices traditionally employed for postpartum discomforts are not evidence based, so both nonpharmacologic and pharmacologic measures are often used in tandem (King et al., 2015).

Applications of Cold and Heat COLD Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. Ice packs are wrapped in a disposable covering or clean washcloth and are applied to the perineal area. Usually the ice pack is applied intermittently for 20 minutes and removed for 10 minutes. Many commercially prepared ice packs are available, but a surgical glove filled with crushed ice and covered can also be used if the mother is not allergic to latex. Ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. HEAT The peribottle is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad. Usually the peribottle is introduced to the woman when she is assisted to the bathroom to freshen up and void for the first time—in most instances, once vital signs are stable after the first hour. Provide the woman with instructions on how and when to use the peribottle. Reinforce this practice each

time she changes her pad, voids, or defecates, making sure that she understands to direct the flow of water from front to back. The woman can take the peribottle home and use it over the next several weeks until her lochia discharge stops. The peribottle can be used by women who had either vaginal or cesarean births to provide comfort and hygiene to the perineal area. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. The change from cold to room temperature therapy enhances vascular circulation and healing. When compared with an infrared light to promote healing and reduce perineal pain, sitz baths were significantly more effective in promoting episiotomy wound healing (Sukhwinder et al., 2014). Before using a sitz bath, the woman should cleanse the perineum with a peribottle or take a shower using mild soap.

FIGURE 16.6 Sitz bath setup.

Most health care agencies use plastic disposable sitz baths that women can take home. The plastic sitz bath consists of a basin that fits on the commode; a bag filled with warm water is hung on a hook and connected via a tube onto the front of the basin (Fig. 16.6). Teaching Guidelines 16.1 highlights the steps in

using a sitz bath.

Teaching Guidelines 16.1

USING A SITZ BATH 1. Close clamp on tubing before filling bag with water to prevent leakage. 2. Fill sitz bath basin and plastic bag with room-temperature water (comfortable to touch). 3. Place the filled basin on the toilet with the seat raised and the overflow opening facing toward the back of the toilet. 4. Hang the filled plastic bag on a hook close to the toilet or an IV pole. 5. Attach the tubing to the opening on the basin. 6. Sit on the basin positioned on the toilet seat and release the clamp to allow warm water to irrigate the perineum. 7. Remain sitting on the basin for approximately 15 to 20 minutes. 8. Stand up and pat the perineum area dry. Apply a clean peripad. 9. Tip the basin to remove any remaining water and flush the toilet. 10. Wash the basin with warm water and soap and dry it in the sink. 11. Store basin and tubing in a clean, dry area until the next use. 12. Wash hands with soap and water. Advise the woman to use the sitz bath several times daily to provide hygiene and comfort to the perineal area. Encourage her to continue this measure after discharge. Some facilities have hygienic sitz baths called Suri-Gators in the bathroom that spray an antiseptic, water, or both onto the perineum. The woman sits on the toilet with legs apart so that the nozzle spray reaches her perineal area. Keep in mind that tremendous hemodynamic changes are taking place within the mother during this early postpartum period, and her safety must be a priority. Fatigue, blood loss, the effects of medications, and lack of food may cause her to feel weak when she stands up. Assisting the woman to the bathroom to instruct

her on how to use the peribottle and sitz bath is necessary to ensure her safety. Many women become light-headed or dizzy when they get out of bed and need direct physical assistance. Staying in the woman’s room, ensuring that the emergency call light is readily available, and being available if needed during this early period will ensure safety and prevent accidents and falls. Recent reviews of the use of postpartum local cooling and warming interventions for perineal pain found limited evidence supporting their effectiveness. Additional studies are needed in the area of perineal pain and healing in order to develop evidence-based interventions in the future (Mooventhan & Nivethitha, 2014).

Topical Preparations Several treatments may be applied topically for temporary relief of perineal pain and discomfort. One such treatment is a local anesthetic spray such as benzocaine topical. These agents numb the perineal area and are used after cleansing the area with water via the peribottle and/or a sitz bath. Postpartum women are predisposed to hemorrhoid development due to pressure during vaginal birth, constipation, relaxation of the smooth muscles in vein walls, and impaired blood return, all related to increased pressure from the heavy gravid uterus. Nonpharmacologic measures to reduce hemorrhoid discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads, such as Tucks®. The pads are placed at the rectal area, between the hemorrhoids and the perineal pad. These pads cool the area, help relieve swelling, and minimize itching. Pharmacologic methods used to reduce hemorrhoid pain include local anesthetics (dibucaine) or steroids (hydrocortisone acetate). Prevention or correction of constipation, encouraging the use of the sidelying position, proper toileting habits, assuming positions that minimize putting pressure on the hemorrhoids, and not straining during defecation will be helpful in reducing discomfort (King et al., 2015). Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breast-feeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Applying expressed breast milk to nipples and

allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breast-feeding to ensure correct positioning can help prevent nipple trauma.

Analgesics Analgesics such as acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are prescribed to relieve mild postpartum discomfort. For moderate to severe pain, a narcotic analgesic such as codeine or oxycodone in conjunction with aspirin or acetaminophen may be prescribed. Instruct the woman about adverse effects of any medication prescribed. Common adverse effects of oral analgesics include dizziness, lightheadedness, nausea and vomiting, constipation, and sedation (Skidmore-Roth, 2015). Also inform the woman that the drugs are secreted in breast milk. Nearly all medications that the mother takes are passed into her breast milk; however, the mild analgesics (e.g., acetaminophen or ibuprofen) are considered relatively safe for breast-feeding mothers (King et al., 2015). Administering a mild analgesic approximately an hour before breast-feeding will usually relieve afterpains and/or perineal discomfort.

Assisting With Elimination The bladder is edematous, hypotonic, and congested immediately postpartum. Consequently, bladder distention, incomplete emptying, and inability to void are common. A full bladder interferes with uterine contraction and may lead to hemorrhage, because it will displace the uterus out of the midline. Encourage the woman to void. Often, assisting her to assume the normal voiding position on the commode facilitates this. If the woman has difficulty voiding, pouring warm water over the perineal area, hearing the sound of running tap water, blowing bubbles through a straw, taking a warm shower, drinking fluids, providing her with privacy, or placing her hand in a basin of warm water may stimulate voiding. If these actions do not stimulate urination within 4 to 6 hours after giving birth, catheterization may be needed. Palpate the bladder for distention and ask the woman if she is voiding in small amounts (less than 100 mL) frequently (retention with overflow). If catheterization is necessary, use sterile technique to reduce the risk of infection. Decreased bowel motility during labor, high iron content in prenatal vitamins, postpartum fluid loss, and the adverse effects of pain medications and/or anesthesia may predispose the postpartum woman to constipation. In addition, the woman may fear that bowel movements will cause pain or injury, especially if she had an episiotomy or a laceration that was repaired with sutures. Usually a stool softener, such as docusate, with or without a laxative might be helpful if the client has difficulty with bowel elimination. Other measures, such as ambulating and increasing fluid and fiber intake, may also help. Nutritional instruction might include increasing fruits and vegetables in the diet; drinking plenty of fluids (8 to 12 cups daily) to keep the stool soft; drinking small amounts of prune juice and/or hot liquids to stimulate peristalsis; eating highfiber foods such as bran cereals, whole grains, dried fruits, fresh fruits, and raw vegetables; and walking daily.

Promoting Activity, Rest, and Exercise The postpartum period is an ideal time for nurses to promote the importance of physical fitness, help women incorporate exercise into their lifestyle, and encourage them to overcome barriers to exercise. The lifestyle changes that occur postpartum may affect a woman’s health for decades. Early ambulation is encouraged to reduce the risk of thromboembolism and to improve strengthening. Many changes occur postpartum, and caring for a newborn alters the woman’s eating and sleeping habits, work schedules, and time allocation. Postpartum fatigue is common during the early days after childbirth, and it may continue for weeks or months. Having adequate sleep is critical for new mothers because shorter sleep time, a high percentage of sleep disturbances, and greater fatigue are associated with depressive symptoms in postpartum women (Bhati & Richards, 2015). Working partners with newborns experience fatigue during early parenthood and are unable to recover due to interrupted and poor sleep patterns. This sleep deficit can compromise their work safety (Parfitt & Ayers, 2014). For women, it affects the mother’s relationships with significant others and her ability to fulfill household and child care responsibilities. Be sure that the mother recognizes her need for rest and sleep and is realistic about her expectations. Some suggestions include the following: • Nap when the infant is sleeping, because getting uninterrupted sleep at night is difficult. • Reduce participation in outside activities and limit the number of visitors. • Determine the infant’s sleep–wake cycles and attempt to increase wakeful periods during the day so the baby sleeps for longer periods at night. • Eat a balanced diet to promote healing and to increase energy levels. • Share household tasks to conserve your energy. • Ask the father or other family members to provide infant care during the night periodically so that mothers can get an uninterrupted night of sleep, if they are not breast-feeding. • Review your family’s daily routine and see if you can “cluster” activities to conserve energy and promote rest.

The demands of parenthood may reduce or prevent exercise in even the most committed person. A targeted exercise program and proper body mechanics can help new mothers deal with the physical challenges of motherhood. Emphasize the benefits of a regular exercise program, which include: • Helps the woman to lose pregnancy weight • Reduces the risk of obesity later in life • Increases overall postpartum well-being • Increases energy level so the woman can cope with her new responsibilities • Speeds the return to prepregnant size and shape • Reduces risk of postpartum depression • Reduces risk of constipation • Reduces mental fatigue • Provides an outlet for stress (Covan, 2015) Overweight and obesity are epidemic in the United States. Obesity is a risk factor for numerous conditions, including diabetes, hypertension, high cholesterol, stroke, heart disease, cancer and arthritis. More than one third of American women are overweight (ACOG, 2014). Although the average gestational weight gain is small (approximately 25 to 35 lb), excess weight gain and failure to lose weight after pregnancy are important predictors of long-term obesity. The postpartum period is a vulnerable time for excessive weight retention, particularly for the increasing number of women who are overweight at the start of their pregnancy and subsequently find it difficult to lose the additional weight gained during pregnancy. Breast-feeding and exercise may help to control weight in the long term (Neville et al., 2014).

Take Note! Women who are unable to return to a healthy weight by 6 months postpartum increase their risk factors for the development of chronic diseases including metabolic syndrome, obesity, and cardiovascular disease (Brekke et al., 2014). Encourage women to lose their pregnancy weight by 6 months postpartum, and refer those who don’t to community weight-loss programs.

The postpartum woman may face some obstacles to exercising, including physical changes (ligament laxity), competing demands (newborn care), lack of information about weight retention (inactivity equates to weight gain), and stress incontinence (leaking of urine during activity). A healthy woman with an uncomplicated vaginal birth can resume exercise in the immediate postpartum period. Advise the woman to start slowly and increase the level of exercise over a period of several weeks as tolerated. Infant strollers/carriers may be an option for some women, allowing them to walk with their newborns for exercise. Jogging strollers can be used later when the infant is 6 to 12 months old and can hold his or her head up. Also, exercise videos and home exercise equipment allow mothers to work out while the newborn naps. Exercising after giving birth promotes feelings of well-being and restores muscle tone lost during pregnancy. Routine exercise should be resumed gradually, beginning with pelvic floor exercises on the first postpartum day and, by the second week, progressing to abdominal, buttock, and thigh-toning exercises. Most postpartum women fail to meet national guidelines for physical activity which may elevate their risk for morbidity and contribute to the intergenerational impact of obesity on their offspring (Downs, Evenson, & Chasan-Taber, 2014). Walking is an excellent form of early exercise as long as the woman avoids jarring and bouncing movements, because joints do not stabilize until 6 to 8 weeks postpartum. Exercising too much too soon can cause the woman to bleed more and her lochia may return to bright red. If this occurs, instruct the woman to stop exercising and rest lying down until the bleeding slows. This increase in bleeding should be a warning to the woman that she is over doing it and needs to slow down her exercise routine. Recommended exercises for the first few weeks postpartum include abdominal breathing, head lifts, modified sit-ups, double knee roll, and pelvic tilt (Teaching Guidelines 16.2). The number of exercises and their duration is gradually increased as the woman gains strength.

Teaching Guidelines 16.2

POSTPARTUM EXERCISES Abdominal Breathing

1. While lying on a flat surface (floor or bed), take a deep breath through your nose and expand your abdominal muscles (they will rise up from your midsection). 2. Slowly exhale and tighten your abdominal muscles for 3 to 5 seconds. 3. Repeat this several times. Head Lift 1. Lie on a flat surface with knees flexed and feet flat on the surface. 2. Lift your head off the flat surface, tuck it onto your chest, and hold for 3 to 5 seconds. 3. Relax your head and return to the starting position. 4. Repeat this several times. Modified Sit-Ups 1. Lie on a flat surface and raise your head and shoulders 6 to 8 inc so that your outstretched hands reach your knees. 2. Keep your waist on the flat surface. 3. Slowly return to the starting position. 4. Repeat, increasing in frequency as your comfort level allows. Double Knee Roll 1. Lie on a flat surface with your knees bent. 2. While keeping your shoulders flat, slowly roll your knees to your right side to touch the flat surface (floor or bed). 3. Roll your knees back over your body to the left side until they touch the opposite side of the flat surface. 4. Return to the starting position on your back and rest. 5. Repeat this exercise several times. Pelvic Tilt 1. Lie on your back on a flat surface with your knees bent and your arms at your side. 2. Slowly contract your abdominal muscles while lifting your pelvis up toward the ceiling. 3. Hold for 3 to 5 seconds and slowly return to your starting position.

4. Repeat several times. Remember that cultures have different attitudes toward exercise. Some cultures (e.g., Haitian, Arab American, Chinese, and Mexican) expect new mothers to observe a specific period of bed rest or activity restriction; thus, it would be inappropriate to recommend active exercise during the early postpartum period (Bowers & Ceballos, 2015).

Preventing Stress Incontinence Fifty percent of all parous women develop some degree of pelvic prolapse in their lifetime that is associated with stress incontinence. Stress incontinence causes reduced quality of life and withdrawal from fitness and exercise activities typically. Research suggests that having a vaginal delivery results in direct pelvic muscle trauma and disruption of fascial supports, and also causes damage to the levator ani muscle and pudendal nerve injury. Offering pelvic floor muscle exercise instruction to all women during their first pregnancy and again after having a vaginal birth is recommended by the National Institute for Health and Care Excellence (NICE) guidelines. Nurses can offer them as a first-line intervention in the prevention of urinary incontinence postpartum (Hall & Woodward, 2015). The more vaginal deliveries a woman has had, the more likely she is to have stress incontinence. Stress incontinence can occur with any activity that causes an increase in intra-abdominal pressure. Postpartum women might consider low-impact activities such as walking, biking, swimming, or lowimpact aerobics so they can resume physical activity while strengthening the pelvic floor. Suggestions to prevent stress incontinence are: • Start a regular program of pelvic floor muscle exercises after childbirth. • Lose weight if necessary; obesity is associated with stress incontinence. • Avoid smoking; limit intake of alcohol and caffeinated beverages, which irritate the bladder. • Adjust fluid intake to produce a 24-hourly urine output of 1,000 to 2,000 mL. • Use either an intravaginal or intra-urethral device that puts pressure onto the urethra so that urine will not leak when bladder pressure rises (Laliberte, 2015). Pelvic floor exercises (Kegel exercises) help to strengthen the pelvic floor muscles if done properly and regularly (Ciaghi, Bianco, & Guarese, 2015). These pelvic floor strengthening exercises were originally developed by Dr. Arnold Kegel in the 1940s as a method of controlling incontinence in women after childbirth. The principle behind these exercises is that strengthening the muscles of the pelvic floor improves urethral sphincter function. While providing postpartum care, instruct women on primary prevention of

stress incontinence by discussing the value and purpose of pelvic floor muscle exercises. Approach the subject sensitively, avoiding the term incontinent. The terms leakage, loss of urine, or bladder control issues are more acceptable to most women.

Take Note! When properly performed, pelvic floor exercises have been effective in preventing or improving urinary continence (Jones & Hawkes, 2015). Women can perform pelvic floor exercises, doing ten 5-second contractions, whenever they change diapers, talk on the phone, or watch TV. Teach the woman to perform pelvic floor exercises properly; help her to identify the correct muscles by trying to stop and start the flow of urine when sitting on the toilet (Teaching Guidelines 16.3). Pelvic floor exercises can be done without anyone knowing.

Teaching Guidelines 16.3

PERFORMING PELVIC FLOOR MUSCLE EXERCISES 1. Identify the correct pelvic floor muscles by contracting them to stop the flow of urine while sitting on the toilet. 2. Repeat this contraction several times to become familiar with it. 3. Start the exercises by emptying the bladder. 4. Tighten the pelvic floor muscles and hold for 10 seconds. 5. Relax the muscle completely for 10 seconds. 6. Perform 10 exercises at least three times daily. Progressively increase the number that you perform. 7. Perform the exercises in different positions, such as standing, lying, and sitting. 8. Keep breathing during the exercises.

9. Don’t contract your abdominal, thigh, leg, or buttocks muscles during these exercises. 10. Relax while doing pelvic floor exercises and concentrate on isolating the right muscles. 11. Attempt to tighten your pelvic muscles before sneezing, jumping, or laughing. 12. Remember that you can perform these exercises anywhere without anyone noticing.

Assisting With Self-Care Measures Demonstrate and discuss with the woman ways to prevent infection during the postpartum period. Because she may experience lochia drainage for as long as a month after childbirth, describe practices to promote well-being and healing. These measures include: • Frequently change perineal pads, applying and removing them from front to back to prevent spreading contamination from the rectal area to the genital area. • Avoid using tampons after giving birth to decrease the risk of infection. • Shower once or twice daily using a mild soap. Avoid using soap on nipples. • Use a sitz bath after every bowel movement to cleanse the rectal area and relieve enlarged hemorrhoids. • Use the peribottle filled with warm water after urinating and before applying a new perineal pad. • Avoid tub baths for 4 to 6 weeks, until joints and balance are restored, to prevent falls. • Wash your hands before changing perineal pads, after disposing of soiled pads, and after voiding (Mattson & Smith, 2016). To reduce the risk of infection at the episiotomy site, reinforce proper perineal care with the client, showing her how to rinse her perineum with the peribottle after she voids or defecates. Stress the importance of always patting gently from front to back and washing her hands thoroughly before and after perineal care. For hemorrhoids, have the client apply witch hazel-soaked pads (Tucks®), ice packs to relieve swelling, or hemorrhoidal cream or ointment if ordered.

Ensuring Safety One of the safety concerns during the postpartum period is orthostatic hypotension. When the woman rapidly moves from a lying or sitting position to a standing one, her blood pressure can suddenly drop, causing her pulse rate to increase. She may become dizzy and faint. Be aware of this problem and initiate the following safeguards: • Check blood pressure first before ambulating the client. • Elevate the head of the bed for a few minutes before ambulating the client. • Have the client sit on the side of the bed for a few moments before getting up. • Help the client to stand up, and stay with her. • Ambulate alongside the client and provide support if needed. • Frequently ask the client how her head feels. • Stay close by to assist if she feels light-headed. Additional topics to address orthostatic hypotension that may concern infant safety include instructing the woman to place the newborn back in the crib on his or her back if she is feeling sleepy to prevent a fall. If the woman falls asleep while holding the infant, she might drop him or her. Also, instruct mothers to keep the door to their room closed when their infant is in their room with them. They should check the identification of anyone who enters their room or who wants to take the infant out of the room. This will prevent infant abduction.

Counseling About Sexuality and Contraception Pregnancy and childbirth are special periods in a woman’s life that involve significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of a couple’s sexual relationship. This is often a time period filled with excitement, changes, and challenges. Mothers often face changes in their own sexuality in their adjustment to motherhood. Sexuality is an important part of every woman’s life. Women want to get back to “normal” as soon as possible after giving birth, but a couple’s sexual relationship cannot be isolated from the psychological and psychosocial adjustments that both partners are going through. Childbirth is a significant life transition that has a measurable impact on postpartum women’s sexual function. There are physical (perineal pain), psychological (depression), and contextual factors (motherhood) that contribute to the change in many women’s sex lives after experiencing childbirth. Postpartum women may hesitate to resume sexual relations for a number of reasons. Many postpartum women have fatigue, weakness, loss of sexual desire, perception of decreased attractiveness, change in body appearance, vaginal bleeding, perineal discomfort, hemorrhoids, sore breasts, decreased vaginal lubrication resulting from low estrogen levels, and dyspareunia. Fatigue, the physical demands made by the infant, and the stress of new roles and responsibilities may stress the emotional reserves of couples. New parents may not get much privacy or rest, both of which are necessary for sexual pleasure (Whittock, 2015). Men may feel they now have a secondary role within the family, and they may not understand their partner’s daily routine. The delicate nature of postpartum sexuality makes it difficult for couples to discuss. These issues, combined with the woman’s increased investment in the mothering role, can strain the couple’s sexual relationship. Although couples are reluctant to ask, they often want to know when they can safely resume sexual intercourse after childbirth. Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. However, there is no set, prescribed time at which to resume sexual intercourse after childbirth. There is no scientific basis for the traditional recommendation to delay sexual activity until the six week postpartum check-up.

Each couple must set their own time frame when they feel it is appropriate to resume sexual intercourse. Despite fears and myths about sexual activity during pregnancy, maintaining a couple’s sexual interactions throughout pregnancy and the postpartum period can promote sexual health and well-being and a greater depth of intimacy. Postpartum sexual health and sexual problems are common, which receive little attention from health care providers during the postpartum period, need to be addressed (Halford, Petch, & Creedy, 2015). When counseling the couple about sexuality, determine what knowledge and concerns the couple have about their sexual relationship. Inform the couple that fluctuations in sexual interest are normal. Reassure the breast-feeding mother that she may notice a let-down reflex during orgasm and find her breasts are very sensitive when touched by her partner. Also inform the couple about how to prevent discomfort. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breast-feeding. Use of water-based gel lubricants (K-Y® jelly, Astroglide) can help. Pelvic floor exercises, in addition to preventing stress incontinence, can also enhance sensation. Initiation of contraception during the postpartum period is important to prevent unintended pregnancy and short birth intervals, which can lead to negative health outcomes for mother and infant. Contraceptive options should be included in the discussions with the couple so that they can make an informed decision before resuming sexual activity. Many couples are overwhelmed with the amount of new information given to them during their brief hospitalization, so many are not ready for a lengthy discussion about contraceptives. Presenting a brief overview of the options, along with literature, may be appropriate. It may be suitable to ask them to think about contraceptive needs and preferences and advise them to use a barrier method (condom with spermicidal gel or foam) until they choose another form of contraception. This advice is especially important if the follow-up appointment will not occur for 4 to 6 weeks after childbirth, because many couples will resume sexual activity before this time. Some postpartum women ovulate before their menstrual period returns and thus need contraceptive protection to prevent another pregnancy. Recently, the CDC assessed evidence regarding the safety of estrogencontaining contraceptive methods use during the postpartum period. They recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for VTE during this period. During days 21 to 42 postpartum, women without risk factors for

VTE generally can initiate estrogen-containing contraceptives, but women with risk factors for VTE (e.g., previous VTE or recent cesarean delivery) generally should not use these methods. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply (Centers for Disease Control and Prevention [CDC], 2015a). Open and effective communication is necessary for effective contraceptive counseling so that information is clearly understood. Provide clear, consistent information appropriate to the woman and her partner’s language, culture, and educational level. This will help the couple select the best contraceptive method. Research supports that postpartum education about contraception leads to more contraception use and fewer unplanned pregnancies and that both short-term and multiple-contact interventions had effects. The use of contraceptives was highest when contraceptive counseling was provided prenatally and again in the postpartum period (Zapata et al., 2015).

Promoting Maternal Nutrition The postpartum period can be a stressful one for myriad reasons, such as fatigue, the physical stress of pregnancy and birth, and the nonstop work required to take care of the newborn and to meet the needs of other family members. As a result, the new mother may ignore her own nutrition needs. Whether she is breastfeeding or bottle-feeding, encourage the new mother to take good care of herself and eat a healthy diet so that the nutrients lost during pregnancy can be replaced and she can return to a healthy weight. In general, nutrition recommendations for the postpartum woman include the following: • Eat a wide variety of foods with high nutrient density. • Eat meals that require little or no preparation. • Avoid high-fat fast foods. • Drink plenty of fluids daily—at least 2,500 mL (approximately 84 oz). • Avoid fad weight-reduction diets and harmful substances such as alcohol, tobacco, and drugs. • Avoid excessive intake of fat, salt, sugar, and caffeine. • Eat the recommended daily servings from each food group (Box 16.4).

Nutrition for the Breast-Feeding Mother The breast-feeding mother’s nutritional needs are higher than they were during pregnancy. The mother’s diet and nutritional status influence the quantity and quality of breast milk. Recently, the American Academy of Pediatrics (2014a) recommended that breast-feeding women consume foods that contain iodine, an element that is crucial to healthy brain development and may be lacking in their present diets. Iodine is necessary to produce thyroid hormone, which in turn helps brain development. To meet the needs for breast milk production, the woman’s nutritional needs increase as follows: • Calories: +500 cal/day for the first and second 6 months of lactation • Protein: +20 g/day, adding an extra 2 cups of skim milk • Calcium: +400 mg daily—consumption of four or more servings of milk • Iodine: 290 μg daily—dairy products, seafood and iodized salt

• Fluid: +2 to 3 quarts of fluids daily (milk, juice, or water); no sodas

BOX 16.4 NUTRITIONAL RECOMMENDATIONS FOR NUTRITION DURING THE POSTPARTUM PERIOD

Recommendations for the Lactating Woman from the Food Guide MyPlate • Fruits: 4 servings • Vegetables: 4 servings • Milk: 4 to 5 servings • Bread, cereal, pasta: 12 or more servings • Meat, poultry, fish, eggs: 7 servings • Fats, oils, and sweets: 5 servings (Dudek, 2014).

General Dietary Guidelines for Americans from the Food Guide on MyPlate (for the Nonlactating Woman) • Fruits: Make half of your plate fruits and vegetables. • Vegetables: Eat red, orange, and dark-green vegetables. • Milk: Switch to skim milk or 1%. • Breads, grains, and cereals should be whole grains. • Meat, poultry, fish, eggs: Eat seafood twice a week and beans, which are high in fiber. • Eat the right amount of calories for you; enjoy your food, but eat less. • Be physically active your way in activities that you enjoy. • Fats, oils, and sweets: Cut back on these. • Use food labels to help you make better choices (U. S. Department of Agriculture [USDA] & U.S. Department of Health and Human Services [USDHHS], 2014).

Some foods eaten by the breast-feeding mother may affect the flavor of the breast milk or cause gastrointestinal problems for the infant. Not all infants are affected by the same foods. It is suggested that the mother identify the food item that may be causing a problem for the infant and reduce or eliminate her intake of it. Nutritional needs for breast-feeding mothers are based on the nutritional content of breast milk and the energy expended to produce it. If intake of calories exceeds the energy expended, weight gain occurs. The highest incidence of obesity in women occurs during the childbearing years. Women need to be made aware that weight gained during their reproductive years will have a negative impact on their health as they age. Nurses can assist women in their postpartum weight management program by assessing their readiness to change to lose their pregnancy weight gain; assessing their breast-feeding status, dietary intake, and activity levels; and assessing them for stress and depressive symptoms, which might hinder their weight loss (Green, 2016).

Take Note! During a woman’s brief stay in a health care facility, she may demonstrate a healthy appetite and eat well. Nutritional problems usually start at home when the mother needs to make her own food selections and prepare her own meals. This is a crucial area to address during follow-up.

Supporting the Woman’s Choice of Infant Feeding Method The AAP, WHO, ANA, IOA, USDHHS, ADA, and USPSTF have all released position statements in support of breast-feeding and nurses, should be encouraging it as part of evidence-based practice (Edelman, Kudzma, & Mandle, 2014). Although there is considerable evidence that breast-feeding has numerous health benefits for both mother and infant, many mothers choose to feed their infants formula for the first year of life. Nurses must be able to deliver sound, evidence-based information to help the new mother choose the best way to feed her infant and must support her in her decision. Research findings indicate that parents do listen to nurse’s instruction on feeding practices (Stagg & Ustianov, 2015). Many factors affect a woman’s choice of feeding method, such as culture, employment demands, support from significant others and family, and knowledge base. Although breast-feeding is encouraged, be sure that couples have the information they need to make an informed decision. Whether a couple chooses to breast-feed or bottle-feed the newborn, support and respect their choice.

Women Who Should Not Breast-Feed Certain women should not breast-feed. Drugs such as antithyroid drugs, antineoplastic drugs, alcohol, herpes infection on the breasts, or street drugs (methamphetamines, cocaine, PCP, marijuana) enter the breast milk and would harm the infant, so women taking these substances should not breast-feed. To prevent HIV transmission to the newborn, women who are HIV positive should not breast-feed. Other contraindications to breast-feeding include a newborn with an inborn error of metabolism such as galactosemia or phenylketonuria (PKU), active tuberculosis, or a mother with a serious mental health disorder that would prevent her from remembering to feed the infant consistently (Denne, 2015).

Providing Assistance With Breast-Feeding and Bottle-Feeding First-time mothers often have many questions about feeding, and even women who have had experience with feeding may have questions. Regardless of

whether the postpartum woman is breast-feeding or bottle-feeding her newborn, she can benefit from instruction. PROVIDING ASSISTANCE WITH BREAST-FEEDING The AAP (2014b) recommends breast-feeding for all full-term newborns. Exclusive breast-feeding is sufficient to support optimal growth and development for approximately the first 6 months of life. Breast-feeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child. Educating a mother about breast-feeding will increase the likelihood of a successful breast-feeding experience. At birth, all newborns should be quickly dried, assessed, and, if stable, placed immediately in uninterrupted skin-to-skin contact (kangaroo care) with their mother. This is good practice whether the mother is going to breast-feed or bottle-feed her infant. Numerous benefits of kangaroo care have been reported related to physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breast-feeding duration, and degree of exclusivity), domains, as an effective therapy to relieve procedural pain, and improve neurodevelopment. In addition, kangaroo care provides the newborn with optimal physiologic stability, warmth, and opportunities for the first feed (Campbell-Yeo et al., 2015). The benefits of breast-feeding for infants are clear (see Chapter 18). To promote breast-feeding, the Baby-Friendly Hospital Initiative, an international program of the World Health Organization and the United Nations International Children’s Emergency Fund (UNICEF), was started in 1991. This global health promotion initiative was put forth to improve maternal-infant health by improving rates of exclusive breast-feeding. As part of this program, the hospital or birth center should take the following 10 steps to provide “an optimal environment for the promotion, protection, and support of breast-feeding”: 1. Have a written breast-feeding policy that is communicated to all staff. 2. Educate all staff to implement this written policy. 3. Inform all women about the benefits and management of breast-feeding. 4. Show all mothers how to initiate breast-feeding within 30 minutes of birth. 5. Give no food or drink other than breast milk to all newborns. 6. Demonstrate to all mothers how to initiate and maintain breast-feeding. 7. Encourage breast-feeding on demand.

8. Allow no pacifiers to be given to breast-feeding infants. 9. Establish breast-feeding support groups and refer mothers to them. 10. Practice rooming-in 24 hours daily (Cleminson et al., 2015; CDC, 2015a; World Health Organization [WHO], 2014a). The nurse is responsible for protecting, promoting and supporting breastfeeding when appropriate. For the woman who chooses to breast-feed her infant, the nurse or lactation consultant will need to spend time instructing her about how to do so successfully. Many women have the impression that breast-feeding is simple. Although it is a natural process, women may experience some difficulty in breast-feeding their newborns. Nurses can assist mothers in smoothing out this transition. Assist and provide one-to-one instruction to breast-feeding mothers, especially first-time breast-feeding mothers, to ensure correct technique. Suggestions are highlighted in Teaching Guidelines 16.4 (see Evidence-Based Practice 16.2).

Take Note! Some newborns “latch on and catch on” right away, and others take more time and patience. Inform new mothers about this to reduce their frustration and uncertainty about their ability to breast-feed. Tell mothers that they need to believe in themselves and their ability to accomplish this task. They should not panic if breast-feeding does not go smoothly at first; it takes time and practice. Additional suggestions to help mothers relax and feel more comfortable breast-feeding, especially when they return home, include the following: • Select a quiet corner or room where you won’t be disturbed. • Use a rocking chair to soothe both you and your infant. • Take long, slow deep breaths to relax before nursing. • Drink while breast-feeding to replenish body fluids. • Listen to soothing music while breast-feeding. • Cuddle and caress the infant while feeding. • Set out extra cloth diapers within reach to use as burping cloths.

• Allow sufficient time to enjoy each other in an unhurried atmosphere. • Involve other family members in all aspects of the infant’s care from the start. • Contact a local La Leche or Nursing Mother’s group for continued guidance/support.

EVIDENCE-BASED PRACTICE 16.2 NURSES IMPROVING THE HEALTH OF MOTHERS AND INFANTS BY DANCING THE 10 STEPS TO SUCCESSFUL BREAST-FEEDING

STUDY The Baby Friendly Hospital Initiative has gained momentum in the United States in recent years. The principles of it are evidence-based and that promoting breast-feeding improves health outcomes and neurocognitive development in infants. The purpose of this study was to implement the Ten Steps to Successful Breast-feeding and see if the rates and duration of breastfeeding improved. The implementation strategies included assessment of current practices, identification of barriers and opportunities, and strategies to support changes in 89 hospitals that participated. The initiative was to increase the number of Baby Friendly designated hospitals over a 2-year process-improvement time frame.

Findings Results included heightened professional environment of competence, enhanced delivery of client centered care, improved health of mothers and infants, increased client satisfaction, and achievement of benchmarks. The implementation of the Ten Steps to Successful Breast-feeding resulted in improved rates of breast-feeding in all 89 hospitals.

Nursing Implications This study demonstrated the positive effect of a nurse-led initiative that improved the continuum of care for mothers and infants from the prenatal period through post discharge community care. Nurses can be instrumental by applying principles of evidence-based practices and bring forth change within their health care agencies to improve the outcomes for mothers and their infants. Adapted from Allen, M., Schafer, D. J. (2015). Nurses improving the health of mothers and infants by dancing the 10 steps to successful breastfeeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44, S52

Teaching Guidelines 16.4

BREAST-FEEDING SUGGESTIONS 1. Explain that breast-feeding is a learned skill for both parties. 2. Offer a thorough explanation about the procedure. 3. Instruct the mother to wash her hands before starting. 4. Inform her that her afterpains will increase during breast-feeding. 5. Make sure the mother is comfortable (pain-free) and not hungry. 6. Tell the mother to start the feeding with an awake and alert infant showing hunger signs. 7. Assist the mother to position herself correctly for comfort. 8. Urge the mother to relax to encourage the let-down reflex. 9. Guide the mother’s hand to form a “C” to access the breast with thumb on top and other four fingers under the breast. 10. Have the mother lightly tickle the infant’s upper lip with her nipple to stimulate the infant to open the mouth wide. 11. Aid her in helping the infant to latch on by bringing the infant rapidly to

the breast with a wide-open mouth. 12. Show her how to check that the newborn’s mouth position is correct, and tell her to listen for a sucking noise. 13. Demonstrate correct removal from the breast, using her finger to break the suction. 14. Instruct the mother on how to burp the infant before changing from one breast to another. 15. Show her different positions, such as cradle and football holds and sidelying positions (see Chapter 18). 16. Reinforce and praise the mother for her efforts. 17. Allow ample time to answer questions and address concerns. 18. Refer the mother to support groups and community resources. Because obesity in America is increasing in all walks of life, it is important for nurses to be knowledgeable about how it impacts breast-feeding and ways to support the obese mother. Research shows that mothers who are obese (BMI > 30) are less likely to initiate lactation, have difficulties with latching on, have delayed lactogenesis, experience mechanical challenges, and are prone to early cessation of breast-feeding (Shannon, Chao, & Ramos, 2015). Obesity rates are highest among African American women, who have the lowest rate of breastfeeding initiation and shortest duration when compared with Hispanic and White women. Women who are overweight and obese have lowered prolactin responses to infant sucking, thus milk production may be inhibited. Lactation plays a significant role in preventing future obesity in both the mother and the infant (Masho, Cha, & Morris, 2015).

Nurses can assist in managing obesity-related lactation challenges by keeping the mother and newborn together to facilitate early and frequent sucking to trigger prolactin and oxytocin production, which will help negate the obesityrelated blunting of the prolactin response. Suggesting a sandwich technique to insert the mother’s breast into the newborn’s mouth to elicit sucking might be helpful for the mother with large breasts. In the sandwich technique, the mother is taught to grasp her breast by making a “C” with her thumb and index finger. The thumb stabilizes the top of the breast while the remaining four fingers support her breast from below. Massage or pumping the breast may soften and extend the nipple for easier infant latch-on. In short, nurses can make a difference by observing lactation, assessing infant hydration and satisfaction, and reassuring the mother about her breast-feeding capacity.

PROVIDING ASSISTANCE WITH BOTTLE-FEEDING If the mother or couple has chosen to bottle-feed their newborn, the nurse should respect and support their decision. Discuss with the parents what type of formula they will use. Commercial formulas are classified as cow’s milk-based (Enfamil, Similac), soy protein-based (Isomil, Prosobee, Nursoy), or specialized or therapeutic formulas for infants with protein allergies (Nutramigen, Pregestimil, Alimentum). Commercial formulas can also be purchased in various forms: powdered (must be mixed with water), condensed liquid (must be diluted with equal amounts of water), ready to use (poured directly into bottles), and prepackaged (ready to use in disposable bottles). Breast milk is a dynamic fluid with compositional changes occurring throughout the period of lactation that reflects the growth rate and developmental needs of the infant. Infant formula, in contrast, has a static composition, intended to meet the nutritional requirements of infants from birth to 12 months of age (Lönnerdal & Hernell, 2015). Nurses need to bring this information to the attention of mothers who choose to formula feed their infants that changes may be needed in different stages of growth to meet the nutritional needs of their infant. Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2014). Therefore, explain to parents that a newborn will need 2 to 4 ounces to feel satisfied at each feeding. Until about age 4 months, most bottle-fed infants need six feedings a day. After this time, the number of feedings declines to accommodate other foods in the diet, such as fruits, cereals, and vegetables (Dudek, 2014). For more information on newborn nutrition and bottle feeding, see Chapter 18. When teaching the mother about bottle-feeding, provide the following guidelines: • Wash hands with soap and water and dry using a clean or disposable cloth. • Make sure all bottles, nipples and other utensils are clean. • Make feeding a relaxing time, a time to provide both food and comfort to your newborn. • Use the feeding period to promote bonding by smiling, singing, making eye contact, and talking to the infant. • Powdered formula mixes more easily and the lumps dissolve faster if you use room-temperature water.

• Store any formula prepared in advance in the refrigerator to keep bacteria from growing. • Do not microwave formula; the microwave won’t heat it evenly, causing hot spots. • Always hold the newborn when feeding. Never prop the bottle. • Use a comfortable position when feeding the newborn. Place the newborn in your dominant arm, which is supported by a pillow. Or have the newborn in a semi-upright position supported in the crook of your arm. (This position reduces choking and the flow of milk into the middle ear.) • Tilt the bottle so that the nipple and the neck of the bottle are always filled with formula. This prevents the infant from taking in too much air. • Stimulate the sucking reflex by touching the nipple to the infant’s lips. • Refrigerate any powdered formula that has been combined with tap water. • Discard any formula not taken; do not keep it for future feedings. • Burp the infant frequently, and place the baby on his or her back for sleeping. • Use only iron-fortified infant formula for the first year (Moses, 2014).

Teaching About Breast Care Regardless of whether or not the mother is breast-feeding her newborn, urge her to wear a very supportive, snug bra 24 hours a day to support enlarged breasts and promote comfort. A woman who is breast-feeding should wear a supportive bra throughout the lactation period. A woman who is not nursing should wear it until engorgement ceases, and then should wear a less restrictive one. The bra should fit snugly while still allowing the mother to breathe without restriction. All new mothers should use plain water to clean their breasts, especially the nipple area; soap is drying and should be avoided.

Assessing the Breasts Instruct the mother how to examine her breasts daily. Daily assessment includes the milk supply (breasts will feel full as they are filling), the condition of the nipples (red, bruised, fissured, or bleeding), and the success of breast-feeding. The fullness of the breasts may progress to engorgement in the breast-feeding mother if feedings are delayed or breast-feeding is ineffective. Palpating both breasts will help identify whether the breasts are soft, filling, or engorged. A similar assessment of the breasts should be completed on the nonlactating mother to identify any problems, such as engorgement or mastitis.

Alleviating Breast Engorgement Breast engorgement usually occurs during the first week postpartum. It is a common response of the breasts to the sudden change in hormones and the presence of an increased amount of milk. Reassure the woman that this condition is temporary and usually resolves within 72 hours. ALLEVIATING BREAST ENGORGEMENT IN THE BREAST-FEEDING WOMAN If the mother is breast-feeding, encourage frequent feedings, at least every 2 to 3 hours, using manual expression just before feeding to soften the breast so the newborn can latch on more effectively. Advise the mother to allow the newborn to feed on the first breast until it softens before switching to the other side. See Chapter 18 for more information on alleviating breast engorgement and other common breast-feeding concerns.

ALLEVIATING BREAST ENGORGEMENT AND SUPPRESSING LACTATION IN THE BOTTLE-FEEDING WOMAN If the woman is bottle-feeding, explain that breast engorgement is a self-limiting phenomenon that disappears as increasing estrogen levels suppress milk formation (i.e., lactation suppression). Encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts. Medication is no longer given to hasten lactation suppression because these agents had limited effectiveness and adverse side effects. Teaching Guidelines 16.5 provides tips on lactation suppression.

Teaching Guidelines 16.5

SUPPRESSING LACTATION 1. Wear a supportive, snugly fitting bra 24 hours daily, but not one that binds the breasts too tightly or interferes with your breathing. 2. Suppression may take 5 to 7 days to accomplish. 3. Take mild analgesics to reduce breast discomfort. 4. Let shower water flow over your back rather than your breasts. 5. Avoid any breast stimulation in the form of sucking or massage. 6. Drink to quench your thirst. Restricting your fluid intake will not dry up your milk. 7. Reduce your salt intake to decrease fluid retention. 8. Use ice packs or cool compresses (e.g., cool cabbage leaves) inside the bra to decrease local pain and swelling; change them every 30 minutes (King et al., 2015).

Promoting Family Adjustment and Well-Being The postpartum period involves extraordinary physiologic, psychological, and sociocultural changes in the life of a woman and her family. Adapting to the role of a parent is not an easy process. The postpartum period is a “getting-to-knowyou” time when parents begin to integrate the newborn into their lives as they reconcile the fantasy child with the real one. This can be a very challenging period for families. Nurses play a major role in assisting families to adapt to the changes, promoting a smooth transition into parenthood. Appropriate and timely interventions can help parents adjust to the role changes and promote attachment to the newborn (Fig. 16.7). For couples who already have children, the addition of a new member may bring role conflict and challenges. The nurse should provide anticipatory guidance about siblings’ responses to the new baby, increased emotional tension, child development, and meeting the multiple needs of the expanding family. Although the multiparous woman has had experience with newborns, do not assume that her knowledge is current and accurate, especially if some time has elapsed since her previous child was born. Reinforcing information is important for all families.

Promoting Parental Roles Parents’ roles develop and grow when they interact with their newborn (see Chapter 15 for information on maternal and paternal adaptation). The pleasure they derive from this interaction stimulates and reinforces this behavior. With repeated, continued contact with the newborn, parents learn to recognize cues and understand the newborn’s behavior. This positive interaction contributes to family harmony. Nurses need to know the stages parents go through as they make their new parenting roles fit into their life experience. Assess the parents for attachment behaviors (normal and deviant), adjustment to the new parental role, family member adjustment, social support system, and educational needs. To promote parental role adaptation and parent–newborn attachment, provide the following nursing interventions: • Provide as many opportunities as possible for parents to interact with their newborn. Encourage parents to explore, hold, and provide care for their

newborn. Praise them for their efforts.

FIGURE 16.7 Examples of family members carrying out roles to promote adjustment and well-being. A. An aunt admiring the newest member of the family. B. A father holding his newborn closely on his chest. C. Grandparents welcoming the newest little one to the family circle.

• Model behaviors by holding the newborn close, calling the newborn’s name, and speaking positively.

• Speak directly to the newborn in a calm voice, while pointing out the newborn’s positive features to the parents. • Evaluate the family’s strengths and weaknesses and readiness for parenting. • Assess for risk factors such as lack of social support and the presence of stressors. • Observe the effect of culture on the family interaction to determine healthy family dynamics. • Monitor parental attachment behaviors to determine whether alterations require referral. Positive behaviors include holding the newborn closely or in an en face position, talking to or admiring the newborn, or demonstrating closeness. Negative behaviors include avoiding contact with the newborn, calling it names, or showing a lack of interest in caring for the newborn (see Table 16.1). • Monitor the parents’ coping behaviors to determine alterations that need intervention. Positive coping behaviors include positive conversations between the partners, both parents wanting to be involved with newborn care, and lack of arguments between the parents. Negative behaviors include not visiting, limited conversations or periods of silence, and heated arguments or conflict. • Identify the support systems available to the new family and encourage them to ask for help. Ask direct questions about home or community support. Make referrals to community resources to meet the family’s needs. • Arrange for community home visits in high-risk families to provide positive reinforcement of parenting skills and nurturing behaviors with the newborn. • Provide anticipatory guidance about the following before discharge to reduce the new parents’ frustration: • Newborn sleep–wake cycles (they may be reversed) • Variations in newborn appearance and developmental milestones (growth spurts) • How to interpret crying cues (hunger, wet, discomfort) and what to do about them • Sensory enrichment/stimulation (colorful mobile) • Signs and symptoms of illness and how to assess for fever • Important phone numbers, follow-up care, and needed immunizations • Physical and emotional changes associated with the postpartum period

• Need to integrate siblings into care of the newborn; stress that sibling rivalry is normal and offer ways to reduce it • Ways to make time together for the couple In addition, nurses can help fathers to feel more competent in assuming their parental role by teaching and providing information (Fig. 16.8). Education can dispel any unrealistic expectations they may have, helping them to cope more successfully with the demands of fatherhood and thereby fostering a nurturing family relationship.

Explaining Sibling Roles It can be overwhelming to a young child to have another family member introduced into his or her small, stable world. Although most parents try to prepare siblings for the arrival of their new little brother or sister, many young children experience stress. They may view the new infant as competition, or fear that they will be replaced in the parents’ affection. All siblings need extra attention from their parents and reassurance that they are loved and important. Many parents need reassurance that sibling rivalry is normal. Suggest the following to help parents minimize sibling rivalry:

FIGURE 16.8 Father participating in newborn care.

• Expect and tolerate some regression (thumb sucking, bedwetting). • Explain childbirth in an appropriate way for the child’s age. • Encourage discussion about the new infant during relaxed family times.

• Encourage the sibling(s) to participate in decisions, such as the baby’s name and toys to buy. • Take the sibling on a tour of the maternity suite. • Buy a T-shirt that says “I’m the [big brother or big sister].” • Spend “special time” with the child. • Read with the child. Some suggested titles include: Things to Do With a New Baby (Ormerod, 1984); Betsy’s Baby Brother (Wolde, 1975); The Berenstain Bears’ New Baby (Berenstain, 1974); and Mommy’s Lap (Horowitz & Sorensen, 1993). • Plan time for each child throughout the day. • Role-play safe handling of a newborn, using a doll. Give the preschooler or school-age child a doll to care for. • Encourage older children to verbalize emotions about the newborn. • Purchase a gift that the child can give to the newborn. • Purchase a gift that can be given to the child by the newborn. • Arrange for the child to come to the hospital to see the newborn (Fig. 16.9). • Move the sibling from his or her crib to a youth bed months in advance of the birth of the newborn. • Show the older sibling photos of the baby growing in mommy’s belly. Let them pat the baby beneath the bulge, talk to baby, and feel the baby kick. • Make the older sibling feel important by giving them a title “mommy’s helper.” • Encourage grandparents to pay attention to the older child when visiting. • Tell the older sibling that their friends come and go, but siblings are forever. • Encourage “Do unto others as you would have them do unto you” (Sears & Sears, 2015c).

FIGURE 16.9 Sibling visitation.

Consider This

Katie and Molly have been excited about having a new baby sister ever since they were told about their mother’s pregnancy. The 6-year-old twins are eagerly looking out the front window, waiting for their parents to bring their new sister, Jessica, home. The girls are big enough to help their mother care for their new sibling, and for the past few months they have been fixing up the new nursery and selecting baby clothes. They practiced diapering their dolls—their mother was specific about not using any powder or lotion on Jessica’s bottom—and holding them correctly to feed them bottles. Finally, their mother arrives home from the hospital with Jessica in her arms! The girls notice that their mother is very protective of Jessica and watches them carefully when they care for her. They fight over the opportunity to hold her or feed her. What is special to both of them is the time they spend alone with their parents. Although a new family member has been added, the twins still feel special and loved by their parents.

Thoughts: Bringing a new baby into an established family can cause conflict and jealousy. What preparation did the older siblings have before Jessica arrived? Why is it important for parents to spend time with each sibling separately?

Discussing Grandparents’ Role Grandparents can be a source of support and comfort to the postpartum family if effective communication skills are used and roles are defined. The grandparents’ role and involvement will depend on how close they live to the family, their willingness to become involved, and cultural expectations of their role. Just as parents and siblings go through developmental changes, so too do grandparents. These changes can have a positive or negative effect on the relationship. Newborn care, feeding, and child-rearing practices have changed since the grandparents raised the parents. New parents may lack parenting skills but nonetheless want their parents’ support without criticism. A grandparent’s “takecharge approach” may not be welcome by new parents who are testing their own parenting roles, and family conflict may ensue. However, many grandparents respect their adult children’s wishes for autonomy and remain “resource people” for them when requested.

Take Note! Grandparents’ involvement can enrich the lives of the entire family if accepted in the right context and dose by the family. Nurses can assist in the grandparents’ role transition by assessing their communication skills, role expectations, and support skills during the prenatal period. Find out whether the grandparents are included in the couple’s social support network and whether their support is wanted or helpful. If they are, and it is, then encourage the grandparents to learn about the parenting, feeding, and child-rearing skills their children have learned in childbirth classes. This information is commonly found in “grandparenting” classes, which introduce new parenting concepts and bring the grandparents up to date on today’s childbirth practices.

Teaching About Postpartum Blues The postpartum period is typically a happy yet stressful time, because the birth of an infant is accompanied by enormous physical, social, and emotional changes. The postpartum woman may report feelings of emotional lability, such as crying one minute and laughing the next (see Chapter 15 for postpartum blues discussion). Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. It is prudent to ask two questions—about having pleasure and interest in things, or feeling predominately down, depressed, or hopeless. Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing (King et al., 2015).

Take Note! Postpartum blues have been regarded as brief, benign, and without clinical significance, but several studies have proposed a link between blues and subsequent depression in the 6 months following childbirth (Cristescu et al., 2015). Postpartum blues require no formal treatment other than support and reassurance because they do not usually interfere with the woman’s ability to function and care for her infant. Nurses can ease a mother’s distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur. The postpartum woman also is at risk for postpartum depression and

postpartum psychosis; these conditions are discussed in Chapter 22.

Preparing for Discharge The World Health Organization (WHO) recommends that the length of stay in the health care facility should be individualized for each mother and baby, but should be at least 24 hours after birth (2014b). A shortened hospital stay may be indicated if the following criteria are met: • Mother is afebrile and vital signs are within normal range. • Lochia is appropriate amount and color for stage of recovery. • Hemoglobin and hematocrit values are within normal range. • Uterine fundus is firm; urinary output is adequate. • ABO blood groups and RhD status are known and, if indicated, anti-D immunoglobulin has been administered. • Surgical wounds are healing and no signs of infection are present. • Mother is able to ambulate without difficulty. • Food and fluids are taken without difficulty. • Self-care and infant care are understood and demonstrated. • Family or other support system is available to care for both. • Mother is aware of possible complications (WHO, 2014b).

Providing Immunizations Prior to discharge, check the immunity status for rubella for all mothers and give a subcutaneous injection of rubella vaccine if they are not serologically immune (titer less than 1:8). Be sure that the client signs a consent form to receive the vaccine. The rubella vaccine should not be given to any woman who is immune compromised, and the immune status of her close contacts needs to be determined before any vaccine is administered to her to prevent a more virulent case of the vaccine-preventable illness or potential death. With the recent increase in the number of pertussis in infants younger than three months of age, the CDC is also recommending vaccination with (Tdap) (combination of diphtheria, pertussis, and tetanus vaccines) for the mother during her postpartum stay (CDC, 2015b). Nursing mothers can be vaccinated because the live, attenuated rubella virus is not communicable. Inform all mothers receiving immunization about adverse effects (rash, joint symptoms, and a low-grade fever

5 to 21 days later) and the need to avoid pregnancy for at least 28 days after being vaccinated because of the risk of teratogenic effects (CDC, 2015b).

Rh Status If the client is Rh negative, check the Rh status of the newborn. Verify that the woman is Rh negative and has not been sensitized, that her indirect Coombs’ test (antibody screen) is negative, and that the newborn is Rh positive. Mothers who are Rh negative and have given birth to an infant who is Rh positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process. Administering RhoGAM prevents initial isoimmunization in Rh-negative mothers by destroying fetal erythrocytes in the maternal system before maternal antibodies can develop and maternal memory cells become sensitized. This is a classic passive immunization technique. The usual protocol for the Rh-negative woman is to receive two doses of Rh immunoglobulin (RhoGAM), one at 28 weeks’ gestation and the second dose within 72 hours after childbirth. The standard dose of Rho(D) immune globulin (RhoGAM) is 300 mcg given intramuscularly, which prevents the development of antibodies for an exposure of up to 15 mL of fetal red blood cells (King et al., 2015). A signed consent form is needed after a thorough explanation is provided about the procedure, including its purpose, possible adverse effects, and effect on future pregnancies. RhoGam contains actual Rh antibodies produced by people who have become sensitized. It is therefore, a blood product. Each dose contains enough Anti-D to suppress the immune response of 15 mL of Rh positive red blood cells (Jordan et al., 2014). Jehovah’s Witnesses and others who belong to religions prohibiting the use of blood products should consult their conscience and possibly ecclesiastical leaders about the use of RhoGam. Nurses need to respect whatever their decision is.

Ensuring Follow-Up Care New mothers and their families need to be attended to over an extended period of time by nurses knowledgeable about mother care, infant feeding (breastfeeding and bottle-feeding), infant care, and nutrition. Although continuous nursing care stops on discharge from the hospital or birthing center, extended episodic nursing care needs to be provided at home. Some of the challenges

faced by families after discharge are described in Box 16.5. Many new mothers are reluctant to “cut the cord” after their brief stay in the health care facility and need expanded community services. Women who are discharged too early from the hospital run the risk of uterine subinvolution, discomfort at an episiotomy or cesarean site, infection, fatigue, and maladjustment to their new role. Postpartum nursing care should include a range of family-focused care, including telephone calls, outpatient clinics, and home visits. Typically, public health nurses, community and home health nurses, and the health care provider’s office staff will provide postpartum care after hospital discharge.

BOX 16.5 CHALLENGES FACING FAMILIES AFTER DISCHARGE • Lack of role models for breast-feeding and infant care • Lack of support from the new mother’s own mother if she did not breastfeed • Increased mobility of society, which means that extended family may live far away and cannot help care for the newborn and support the new family • Feelings of isolation and limited community ties for women who work full time • Shortened hospital stays: parents may be overwhelmed by all the information they are given in the brief hospital stay • Prenatal classes usually focus on the birth itself rather than on skills needed to care for themselves and the newborn during the postpartum period • Limited access to education and support systems for families from diverse cultures Adapted from Bope, E., & Kellerman, R. (2015). Conn’s current therapy 2015. Philadelphia, PA: Saunders Elsevier; and Bang, K., Huh, B., & Kwon, M. (2014). The effect of a postpartum nursing intervention program for immigrant mothers. Child Health Nursing Research, 20(1), 11–19.

PROVIDING TELEPHONE FOLLOW-UP Telephone follow-up typically occurs during the first week after discharge to check on how things are going at home. Calls can be made by perinatal nurses within the agency as part of follow-up care or by the local health department nurses. One disadvantage of a phone call assessment is that the nurse cannot see the client and thus must rely on the mother or the family’s observations. The experienced nurse needs to be able to recognize distress and give appropriate advice and referral information if needed. PROVIDING OUTPATIENT FOLLOW-UP For mothers with established health care providers such as private pediatricians

and obstetricians, visits to the office are arranged soon after discharge. For the woman with an uncomplicated vaginal birth, an office visit is usually scheduled for 4 to 6 weeks after childbirth. A woman who had a cesarean birth frequently is seen within 2 weeks after hospital discharge. Hospital discharge orders will specify when these visits should be made. Newborn examinations and further diagnostic laboratory studies are scheduled within the first week.

Take Note! The hospital stay of the mother and her healthy term newborn should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home (WHO, 2014b). Outpatient clinics are available in many communities. If family members run into a problem, the local clinic is available to provide assessment and treatment. Clinic visits can replace or supplement home visits. Although these clinics are open during daytime hours only and the staff members are unfamiliar with the family, they can be a valuable resource for the new family with a problem or concern. PROVIDING HOME VISIT FOLLOW-UP Home visits are usually made within the first week after discharge to assess the mother and newborn. During the home visit, the nurse assesses for and manages common physical and psychosocial problems. In addition, the home nurse can help the new parents adjust to the change in their lives. The postpartum home visit usually includes the following: • Maternal assessment: general well-being, vital signs, breast health and care, abdominal and musculoskeletal status, voiding status, fundus and lochia status, psychological and coping status, family relationships, proper feeding technique, environmental safety check, newborn care knowledge, and health teaching needed (Fig. 16.10 shows sample assessment forms.) • Infant assessment: physical examination, general appearance, vital signs, home safety check, child development status, any education needed to improve parents’ skills

The home care nurse must be prepared to support and educate the woman and her family in the following areas: • Breast-feeding or bottle-feeding technique and procedures • Appropriate parenting behavior and problem solving • Maternal/newborn physical, psychosocial, and culture–environmental needs • Emotional needs of the new family • Warning signs of problems and how to prevent or eliminate them • Sexuality issues, including contraceptive use • Immunization needs for both mother and infant • Family dynamics for smooth transition • Links to health care providers and community resources

FIGURE 16.10 Sample postpartum home visit assessment form. A. Maternal assessment. B. Newborn

assessment. (Used with permission: Copyright Briggs Corporation. Professional Nurse Associates.)

KEY CONCEPTS The transitional adjustment period between birth and parenthood includes education about baby care basics, the role of the new family, emotional support, breast-feeding or bottle-feeding support, and maternal mentoring. Sensitivity to how childbearing practices and beliefs vary for multicultural families and how best to provide appropriate nursing care to meet their needs are important during the postpartum period. A thorough postpartum assessment is key to preventing complications as is frequent hand hygiene by the nurse, especially between handling mothers and infants. The postpartum assessment that uses the acronym BUBBLE-EE (breasts, uterus, bowel, bladder, lochia, episiotomy/perineum/epidural site, extremities, and emotions) is a helpful guide in performing a systematic head-to-toe postpartum assessment. Lochia is assessed according to its amount, color, and change with activity and time. It proceeds from lochia rubra to serosa to alba. Because of shortened agency stays, nurses must use this brief time with the client to address areas of comfort, elimination, activity, rest and exercise, selfcare, sexuality and contraception, nutrition, family adaptation, discharge, and follow-up. The AAP advocates breast-feeding for all full-term newborns, maintaining that, ideally, breast milk should be the sole nutrient for the first 6 months and continued with foods until 12 months of life or longer. Successful parenting is a continuous and complex interactive process that requires the acquisition of new skills and the integration of the new member into the existing family unit. Bonding is a vital component of the attachment process and is necessary in establishing parent–infant attachment and a healthy, loving relationship; attachment behaviors include seeking and maintaining proximity to, and exchanging gratifying experiences with, the infant. Nurses can be instrumental in facilitating attachment by first understanding attachment behaviors (positive and negative) of newborns and parents, and

intervening appropriately to promote and enhance attachment. New mothers and their families need to be attended to over an extended period of time by nurses knowledgeable about mother care, newborn feeding (breastfeeding and bottle-feeding), newborn care, and nutrition.

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Neville, C., McKinley, M., Holmes, V., Spence, D., & Woodside, J. (2014). The effectiveness of weight management interventions in breastfeeding women – A systematic review and critical evaluation. Birth, 41(3), 223–236. Parfitt, Y., & Ayers, S. (2014). Transition to parenthood and mental health in first-time parents. Infant Mental Health Journal, 35, 263–273. Park, S., Kim, S., & Kang, K. (2014). Integrative review of nursing intervention studies on mother-infant interactions. Child Health Nursing Research, 20(2), 75–86. Parker, C., Warmuskerken, G., & Sinclair, L. (2015). Enhancing neonatal wellness with home visitation. Nursing for Women’s Health, 19(1), 36–45. Purnell, L. D. (2014). Guide to culturally competent health care (3rd ed.). Philadelphia, PA: F. A. Davis. Santiago, M., & Figueiredo, M. (2015). Immigrant women’s perspective on prenatal and postpartum care: Systematic review. Journal of Immigrant & Minority Health, 17(1), 276–284. Sears, R. W., & Sears, J. M. (2015a). Bonding – What it means. Retrieved from http://www.askdrsears.com/topics/pregnancy-childbirth/tenth-month-post-partum/bonding-with-yournewborn/bonding-what-it-means. Sears, R. W., & Sears, J. M. (2015b). Attachment parenting. Retrieved from http://www.askdrsears.com/topics/parenting/attachment-parenting. Sears, R. W., & Sears, J. M. (2015c). Introducing a new baby: 11 smooth-entry tips. Retrieved from http://www.askdrsears.com/topics/parenting/discipline-behavior/bothersome-behaviors/siblingrivalry/introducing-new-baby-11 Sette, G., Coppola, G., & Cassibba, R. (2015). The transmission of attachment across generations: The state of art and new theoretical perspectives. Scandinavian Journal of Psychology, 56(3), 315–326. Shannon, C., Chao, M., & Ramos, D. E. (2015). A gap analysis of effective interventions for postpartum weight loss in obese new mothers. Obstetrics & Gynecology, 125, 56–59.. Skidmore-Roth, L. (2015). Mosby’s 2015 nursing drug reference (28th ed.). St. Louis, MO: Mosby Elsevier. Stagg, J., & Ustianov, J. (2015). Improving and sustaining breastfeeding practices through a statewide learning collaborative. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44, S55. Sucker, C., & Zotz, R. B. (2015). Prophylaxis and treatment of venous thrombosis and pulmonary embolism in pregnancy. Reviews in Vascular Medicine, 3(2), 24–30. Sukhwinder, K., Poonam, S., Sulakshna, C., & Jodibala, H. (2014). Comparison of infrared light therapy vs sitz bath on episiotomy in terms of wound healing and intensity of pain among postnatal mothers. International Journal of Nursing Care, 2(1), 37–41. Tester-Jones, M., O’Mahen, H., Watkins, E., & Karl, A. (2015). The impact of maternal characteristics, infant temperament and contextual factors on maternal responsiveness to infant. Infant Behavior & Development, 40, 1–11. U.S. Department of Agriculture [USDA] & U.S. Department of Health and Human Services [USDHHS].

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CHAPTER WORKSHEET MULTIPLE CHOICE QUESTIONS 1. When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia d. Obsessive thoughts and hallucinations 2. Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? a. Taking a transcultural course

b. Caring for only families of his or her cultural origin c. Teaching Western beliefs to culturally diverse families d. Educating himself or herself about diverse cultural practices 3. Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods, breastfeed, increase exercise. c. Start a high-protein, low carbohydrate diet and restrict fluids. d. Eat no snacks or carbohydrates after dinner. 4. After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein d. Iron-rich foods and minerals 5. Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? a. Fatigue and irritability b. Perineal discomfort and pink discharge c. Pulse rate of 60 bpm d. Swollen, tender, hot area on breast 6. Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? a. Holding the infant close to the body b. Having visitors hold the infant c. Buying expensive infant clothes d. Requesting that the nurses care for the infant

7. Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? a. Punishing the older child for bedwetting behavior b. Sending the sibling to the grandparents’ house c. Planning a daily “special time” for the older sibling d. Allowing the sibling to share a room with the infant 8. The major purpose of the first postpartum homecare visit is to: a. Identify complications that require interventions b. Obtain a blood specimen for PKU testing c. Complete the official birth certificate d. Support the new parents in their parenting roles 9. The nurse is instructing the postpartum client who plans to bottle-feed her newborn about measures to prevent breast engorgement when she is discharged. Which of the following measures should the nurse include in the teaching plan? a. Decreasing her fluid intake for the first week at home b. Wearing a tight-fitting supportive bra 24 hours daily c. Take a diuretic to release the extra fluid in the breasts d. Manually express the milk that is accumulating 10. A new mother was brought to the postpartum unit who gave birth 12 hours ago. Because this is her first child, which of the following goals by the nurse is most appropriate? a. Early discharge for the mother and newborn b. Rapid transition into her role of being a parent/caretaker c. Minimal need for expression of her feelings now d. Effective education of both parents before discharge

CRITICAL THINKING EXERCISES

1. As a nurse working on a postpartum unit, you enter the room of, a 22-year-old primipara, and find her chatting on the phone while her newborn is crying loudly in the bassinette, which has been pushed into the bathroom. You pick up and comfort the newborn. While holding the baby, you ask the client if she was aware her newborn was crying. She replies, “That’s about all that monkey does since she was born!” You hand the newborn to her and she places the newborn on the bed away from her and continues her phone conversation. a. What is your nursing assessment of this encounter? b. What nursing interventions would be appropriate? c. What specific discharge interventions may be needed? 2. A 34-year-old single primipara, left the hospital after a 36-hour stay with her newborn son. She lives alone in a one-bedroom walk-up apartment. As the postpartum home health nurse visiting her 2 days later, you find the following: • Tearful client pacing the floor holding her crying son • Home cluttered and in disarray • Fundus firm and displaced to right of midline • Moderate lochia rubra; episiotomy site clean, dry, and intact • Vital signs within normal range; pain rating less than 3 points on scale of 1 to 10 • Breasts engorged slightly; supportive bra on • Newborn assessment within normal limits • Distended bladder upon palpation; reporting urinary frequency a. Which of these assessment findings warrants further investigation? b. What interventions are appropriate at this time, and why? c. What health teaching is needed before you leave this home? 3. The nurse walks into the room of a 24-year-old primigravida. She asks the nurse to hand her the bottle sitting on the bedside table, stating, “I’m going to finish it off because my baby only ate half of it 3 hours ago when I fed him.” a. What response by the nurse would be appropriate at this time? b. What action should the nurse take? c. What health teaching is needed for this new mother prior to discharge?

STUDY ACTIVITIES 1. Identify two questions that a nurse would ask a postpartum woman to assess for postpartum blues. 2. Find a web site that offers advice to new parents about breast-feeding. Critique the site, the author’s credentials, and the accuracy of the content. 3. Outline instructions you would give to a new mother on how to use her peribottle. 4. Breast tissue swelling secondary to vascular congestion after childbirth and preceding lactation describes ___________________. 5. Listen to the postpartum story of one of your assigned clients and share it with your peers in class or as part of online discussion.

BRINGING IT ALL TOGETHER: CASE STUDY A 26-year-old African American woman gave birth to a healthy term neonate yesterday and is preparing for discharge. The mother is illiterate and lives in a poor agricultural area of town not far from the hospital. This is her fourth infant in five years. The postpartum nurse comes into the room and observes that this mother has wrapped a piece of unclean cloth tightly around the infant’s abdomen with a quarter which covers the cord stump. The take-home infant outfit is not clean and not appropriate for the weather conditions outside. The mother is waiting for a ride home from a friend. The postpartum nurse is here to provide her with discharge instructions.

ASSESSMENT Client’s general appearance is healthy, but appears fatigued. Vital signs are as follows: BP 120/74; Pulse 78; Temp 98.2F; Respirations 20 bpm. Her breasts are soft upon palpation, no engorgement present. She plans to bottle-feed her infant. Her abdominal exam is without significant findings and involution is proceeding normally. Fundus is at the level of the umbilicus and firm. Lochia rubra is moderate, with no clots. Voiding well and has had a bowel movement this morning. No episiotomy site to assess. Newborn physical exam was normal per pediatrician’s notes.

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unit six The Newborn

17 Newborn Transitioning

KEY TERMS cold stress jaundice meconium neonatal period neurobehavioral response neutral thermal environment periodic breathing reflex surfactant thermoregulation

Learning Objectives Upon completion of the chapter, you will be able to: 1. Examine the major physiologic changes that occur as the newborn transitions to extrauterine life. 2. Determine the primary challenges faced by the newborn during the transition to extrauterine life. 3. Interpret the factors that influence the initiation of newborn respirations. 4. Compare and contrast the cardiovascular changes that take place from fetal circulation to extrauterine circulation after birth. 5. Relate three characteristics that predispose newborns to heat loss after birth. 6. Distinguish three primary immunoglobulins that help strengthen the newborn’s immunologic system. 7. Differentiate the three behavioral patterns that newborns progress through after birth. 8. Assess the five typical behavioral responses triggered by external stimuli of the newborn. The Healthy Start home care nurse reviewed the client’s file in her car before she got out: 18-year-old primipara, 1 week postpartum with a term newborn girl weighing 7 lb. The new mother, Maria, greeted the nurse at the door and let her inside the house. After performing a postpartum assessment on Maria and an assessment of her newborn daughter, the nurse asked Maria if she had any questions or concerns. Maria’s eyes welled up with tears: she is worried that her daughter can’t see.

Words of Wisdom Newborns can’t always be judged by their outer wrapping; rather, we should focus on the awesome gift inside.

INTRODUCTION When a child is born, the exhaustion and stress of labor are over for the parents, but now the newborn must begin the work of physiologically and behaviorally adapting to the new environment. The first 24 hours of life can be the most precarious (Swanson & Sinkin, 2015). The neonatal period is defined as the first 28 days of life. It is a period of the most dramatic and rapid physiologic changes in humans. After birth, the newborn is exposed to a whole new world of sounds, colors, smells, and sensations. The newborn, previously confined to the warm, dark, wet intrauterine environment, is now thrust into an environment that is much brighter and cooler. As the newborn adapts to life after birth, numerous physiologic changes occur (Table 17.1). Awareness of the adaptations that are occurring forms the foundation for providing support to the newborn during this crucial time. Physiologic and behavioral changes occur quickly during this transition period. Being aware of any deviations from the norm is crucial to ensure early identification and prompt intervention. This chapter describes the physiologic changes of the newborn’s major body systems. It also discusses the behavioral adaptations, including behavioral patterns and the newborn’s behavioral responses, which occur during this transition period.

PHYSIOLOGIC TRANSITIONING The adaptation from the intrauterine to extrauterine environment is complex and difficult, but required for all humans. Maternal medical and fetal conditions can have a profound effect on the successful transition. The mechanics of birth require a change in the newborn for survival outside the uterus. Immediately at birth, respiratory gas exchange, along with circulatory modifications, must occur to sustain extrauterine life. During this time, as newborns strive to attain homeostasis, they also experience complex changes in major organ systems. The newborn’s most dramatic and most rapid extrauterine transitions occur in four interdependent areas: respiratory, circulatory, thermoregulation, and their ability to stabilize their blood glucose levels. All four areas must make successful transitions for the newborn to adapt to extrauterine life. Although the transition usually takes place within the first 6 to 10 hours of life, many adaptations take weeks to attain full maturity.

Cardiovascular System Adaptations During fetal life, the heart relies on certain unique structures that assist it in providing adequate perfusion of vital body parts. The umbilical vein carries oxygenated blood from the placenta to the fetus. The ductus venosus allows the majority of the umbilical vein blood to bypass the liver and merge with blood moving through the vena cava, bringing it to the heart sooner. The foramen ovale allows more than half the blood entering the right atrium to cross immediately to the left atrium, bypassing the pulmonary circulation. The ductus arteriosus connects the pulmonary artery to the aorta, which allows bypassing of the pulmonary circuit. Only a small portion of blood passes through the pulmonary circuit for the main purpose of perfusion of the structure, rather than for oxygenation. The fetus depends on the placenta to provide oxygen and nutrients and to remove waste products. TABLE 17.1 ANATOMIC AND PHYSIOLOGIC COMPARISON OF THE FETUS AND NEWBORN

At birth, the circulatory system must switch from fetal to newborn circulation and from placental to pulmonary gas exchange. Successful transition from fetal to postnatal circulation requires increased pulmonary blood flow, removal of the

placenta, and closure of the intracardiac (foramen ovale) and extracardiac shunts (ductus venosus and ductus arteriosus). These changes are needed to equalize the right ventricular output with that of the left (Stark & Eichenwald, 2016). The physical forces of the contractions of labor and birth, mild asphyxia, increased intracranial pressure as a result of cord compression and uterine contractions, and the cold stress experienced immediately after birth lead to an increased release of catecholamines that is critical for the changes involved in the transition to extrauterine life. The increased levels of epinephrine and norepinephrine stimulate increased cardiac output and contractility, surfactant release, and promotion of pulmonary fluid clearance (Sharma, Ford, & Calvert, 2014).

Fetal to Neonatal Circulation Changes Changes in circulation occur immediately at birth as the fetus separates from the placenta (Fig. 17.1). When the umbilical cord is clamped, the first breath is taken and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Cuneo, 2014). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. The ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed. Over a period of months these fetal vessels form nonfunctional ligaments. Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the newborn’s first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. With closure of this fetal shunt, oxygenated blood is now separated from nonoxygenated blood. The subsequent increase in tissue oxygenation further promotes the increase in systemic blood pressure and continuing blood flow to the lungs. The foramen ovale normally closes functionally at birth when left

atrial pressure increases and right atrial pressure decreases. Permanent anatomic closure, though, really occurs throughout the next several weeks. During fetal life, the ductus arteriosus, located between the aorta and the pulmonary artery, protected the lungs against circulatory overload by shunting blood (right to left) into the descending aorta, bypassing the pulmonary circulation. Its patency during fetal life is promoted by continual production of prostaglandin E2 (PGE2) by the ductus arteriosus (van Vonderen et al., 2014). The ductus arteriosus becomes functionally closed within the first few hours after birth. Oxygen is the most important factor in controlling its closure. Closure depends on the high oxygen content of the aortic blood that results from aeration of the lungs at birth. At birth, pulmonary vascular resistance decreases, allowing pulmonary blood flow to increase and oxygen exchange to occur in the lungs. It occurs secondary to an increase in PO2 coincident with the first breath and umbilical cord occlusion when it is clamped. The ductus venosus shunted blood from the left umbilical vein to the inferior vena cava during intrauterine life. It closes within a few days after birth because this shunting is no longer needed as a result of activation of the liver. The activated liver now takes over the functions of the placenta (which was expelled at birth). The ductus venosus becomes a ligament in extrauterine life. The two umbilical arteries and one umbilical vein begin to constrict at birth because with placental expulsion, blood flow ceases. In addition, peripheral circulation increases. Thus, the vessels are no longer needed and they too become ligaments. Successful transition and closure of the three fetal shunts creates a neonatal circulation where deoxygenated blood returns to the heart through the inferior and superior vena cava. Deoxygenated blood enters the right atrium then into the right ventricle and travels through the pulmonary artery to the pulmonary vascular bed. Oxygenated blood returns through pulmonary veins to the left atrium, the left ventricle, and through the aorta to the systemic circulation (Stave, 2014). Box 17.1 provides a summary of fetal to neonatal circulation.

Heart Rate During the first few minutes after birth, the newborn’s heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm (Creasy et al., 2014). The newborn is highly dependent on heart rate for maintenance of cardiac output and blood pressure. Although blood

pressure is not taken routinely in the healthy term newborn, it is usually highest after birth and reaches a plateau within a week after birth. Cardiac defects may be identified in the newborn nursery by conducting a thorough and systematic physical assessment, including inspection, palpation, auscultation, and measurement of blood pressure and oxygen saturations. The ability of the nurse to identify irregular findings during physical assessment aids rapid identification and treatment.

FIGURE 17.1 Cardiovascular adaptations of the newborn. Note the changes in oxygenation between (A) prenatal circulation and (B) postnatal (pulmonary) circulation.

Take Note! Transient functional cardiac murmurs may be heard during the neonatal period as a result of the changing dynamics of the cardiovascular system at birth (Fillipps & Bucciarelli, 2015). The fluctuations in both the heart rate and blood pressure tend to follow the changes in the newborn’s behavioral state. An increase in activity, such as wakefulness, movement, or crying, corresponds to an increase in heart rate and blood pressure. In contrast, the compromised newborn demonstrates markedly less physiologic variability overall. Tachycardia may be found with volume depletion, cardiorespiratory disease, drug withdrawal, and hyperthyroidism. Bradycardia is often associated with apnea and is often seen with hypoxia.

Blood Volume The blood volume of the newborn depends on the amount of blood transferred from the placenta at birth. It is usually estimated to be 80 to 85 mL/kg of body weight in the term infant (Stave, 2014). However, the volume may vary by as much as 25% to 40%, depending on when clamping of the umbilical cord occurs. Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition. Recent studies indicate that the benefits of delayed cord clamping include improving the newborn’s cardiopulmonary adaptation, preventing iron-deficient anemia in fullterm newborns without increasing hypervolemia-related risks and increased iron stores, increasing blood pressure, improving oxygen transport, and increasing red blood cell flow (McAdams, 2014). Although a tailored approach is required in the case of cord clamping, current available data suggests that delayed cord clamping offers the newborn many benefits physiologically, which include at least a 30% increase in blood volume for term infants and a 50% increase in preterm infants, improvement of systemic blood pressure, increase in the cerebral oxygen index, higher hemoglobin levels at 24 to 48 hours of age, and increased serum iron levels at 4 to 6 months (Kluckow & Hooper, 2015; Leslie, 2015). Cord blood has also been described as “nature’s first stem cell transplant” because it possesses regenerative properties and can grow into different types of cells in the body (van Vonderen et al., 2014).

BOX 17.1 SUMMARY OF FETAL TO NEONATAL CIRCULATION • Clamping umbilical cord at birth eliminates the placenta as a reservoir for blood. • Onset of respirations causes a rise in PO2 in the lungs and a decrease in pulmonary vascular resistance, which… • Increases pulmonary blood flow and increases pressure in the left atrium, which… • Decreases pressure in the right atrium of the heart, which causes closure of the foramen ovale (closes within minutes after birth secondary to a decreased pulmonary vascular resistance and increased left heart pressure). • With an increase in oxygen levels after the first breath, an increase in systemic vascular resistance occurs, which… • Decreases vena cava return, which reduces blood flow in the umbilical vein (constricts, becomes a ligament with functional closing). • Closure of the ductus venosus (becomes a ligament) causes an increase in pressure in the aorta, which forces closure of the ductus arteriosus within 10 to 15 hours after birth.

Professional organizations American Academy of Pediatrics (AAP) (2013) and American College of Obstetricians & Gynecologists (ACOG) (2014) have released opinions that support delayed cord clamping for preterm infants, but endorse further research on this procedure for term infants. WHO (2014) released a report recommending delayed cord clamping for “all births” as a best practice. A recent Cochrane Review on term infants and timing of umbilical cord clamping reported that those with delayed cord clamping had up to a 60% increase in red blood cells, high hemoglobin levels, and higher iron levels at 4 to 6 months. Infants whose cords were clamped early were twice as likely to be iron deficit at 3 to 6 months (Leslie, 2015). So, at this time, there is no uniform agreement about this practice.

Blood Components The fetus has more red blood cells per cubic millimeter than an adult and they have a greater affinity for oxygen at a lower oxygen pressure than adult red blood cells. Fetal red blood cells are larger in size when compared to an adult, thus each cell can carry more oxygen (Stave, 2014). After birth, the red blood cell count gradually increases as the cell size decreases, because the cells now live in an environment with much higher PO2. A newborn’s red blood cells have a life span of 80 to 100 days, compared with 120 days in adults. Hemoglobin initially declines as a result of a decrease in neonatal red cell mass (physiologic anemia of infancy). Leukocytosis (elevated white blood cells) is present as a result of birth trauma soon after birth. The newborn’s platelet count and aggregation ability are the same as those of adults. The newborn’s hematologic values are affected by the site of the blood sample (capillary blood has higher levels of hemoglobin and hematocrit compared with venous blood), placental transfusion (delayed cord clamping and normal shift of plasma to extravascular spaces, which causes higher levels of hemoglobin and hematocrit), and gestational age (increased age is associated with increased numbers of red cells and hemoglobin) (Andersson et al., 2014). Table 17.2 lists normal newborn blood values.

Respiratory System Adaptations The newborn’s transition from fetal to neonatal life includes aeration of the lungs, establishment of pulmonary gas exchange, and changing the fetal circulation into the adult type. Lung aeration leads to the establishment of functional residual capacity, allowing pulmonary gas exchange to start. The first breath of life is a gasp that generates an increase in transpulmonary pressure and results in diaphragmatic descent. Hypercapnia, hypoxia, and acidosis resulting from normal labor become stimuli for initiating respirations. Inspiration of air and expansion of the lungs allow for an increase in tidal volume (amount of air brought into the lungs). Surfactant is a surface tension–reducing lipoprotein found in the newborn’s lungs that prevents alveolar collapse at the end of expiration and loss of lung volume. It lines the alveoli to enhance aeration of gas-free lungs, thus reducing surface tension and lowering the pressure required to open the alveoli. Normal lung function depends on surfactant, which permits a decrease in surface tension at end expiration (to prevent atelectasis) and an increase in surface tension during lung expansion (to facilitate elastic recoil on inspiration). Surfactant provides the lung stability needed for gas exchange. The newborn’s first breath, in conjunction with surfactant, overcomes the surface forces to permit aeration of the lungs. The chest wall of the newborn is floppy because of the high cartilage content and poorly developed musculature. Thus, accessory muscles to help in breathing are ineffective. TABLE 17.2 NORMAL NEWBORN BLOOD VALUES

One of the most crucial adaptations that the newborn makes at birth is adjusting from a fluid-filled intrauterine environment to a gaseous extrauterine environment. During fetal life, the lungs are expanded with an ultrafiltrate of the amniotic fluid. During and after birth, this fluid must be removed and replaced with air. Passage through the birth canal allows intermittent compression of the thorax, which helps eliminate the fluid in the lungs. Pulmonary capillaries and the lymphatics remove the remaining fluid. If fluid is removed too slowly or incompletely (e.g., with decreased thoracic squeezing during birth or diminished respiratory effort), transient tachypnea (respiratory rate above 60 bpm) of the newborn occurs. Examples of situations involving decreased thoracic compression and diminished respiratory effort include cesarean birth and sedation in newborns. Research findings support the need for thoracic compression because the absence of the neonate’s exposure to labor contractions, which may occur with cesarean births or heavy sedation during the labor process or general anesthesia administered during the surgical birth, is associated with an increased risk of transient tachypnea at term, with oxygen supplementation being needed for a longer duration (Hooper, Polglase, & Roehr, 2015).

Take Note!

A neonate born by cesarean section does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal delivery. Closely observe the respirations of the newborn after cesarean delivery.

Lungs Before the newborn’s lungs can maintain respiratory function, the following events must occur: • Initiation of respiratory movement • Expansion of the lungs • Establishment of functional residual capacity (ability to retain some air in the lungs on expiration) • Increased pulmonary blood flow • Redistribution of cardiac output (Bope & Kellerman, 2015) Initial breathing is probably the result of a reflex triggered by pressure changes, noise, light, temperature changes, touching, compression of the fetal chest during the birthing process, and high carbon dioxide and low oxygen concentrations of the newborn’s blood. Central chemoreceptors stimulated by hypoxia and hypercapnia further increase the respiratory drive. Many theories address the initiation of respiration in the newborn, but most are based on speculation from observations rather than on empirical research (Sharma et al., 2014). Research continues to search for answers to these questions.

Respirations After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). The newborn’s respiratory rate varies according to his or her activity; the more active the newborn, the higher the respiratory rate, on average. Signs of respiratory distress to observe for include cyanosis, tachypnea, expiratory grunting, sternal retractions, and nasal flaring. Respirations should not be labored, and the chest movements should be symmetric. In some cases, periodic breathing may occur, which is the cessation of breathing that lasts 5 to 10 seconds without changes in color or heart rate (Davidson, 2014). Periodic breathing may be observed in newborns within the first few days of life and requires close monitoring.

Take Note! Apneic periods lasting more than 15 seconds with cyanosis and heart rate changes require further evaluation (Mattson & Smith, 2015).

Body Temperature Regulation Newborns are dependent on their environment for the maintenance of body temperature, much more so immediately after birth than later in life. One of the most important elements in a newborn’s survival is obtaining a stable body temperature to promote an optimal transition to extrauterine life. On average, a newborn’s temperature ranges from 97.9° to 99.7°F (36.6° to 37.6°C). Since newborns lose heat easily after birth, having skin-to-skin contact with their mothers is recommended as the initial method for maintaining newborn body temperature. Skin-to-skin contact should be the first line of treatment for hypothermia and as a measure to reduce discomfort from painful procedures. See Evidence-Based Practice 17.1. Thermoregulation is the process of maintaining the balance between heat loss and heat production in order to maintain the body’s core internal temperature. It is a critical physiologic function that is closely related to the transition and survival of the newborn. An appropriate thermal environment is essential for maintaining a normal body temperature. Compared with adults, newborns tolerate a narrower range of environmental temperatures and are extremely vulnerable to both under heating and overheating. Nurses play a key role in providing an appropriate environment to help newborns maintain thermal stability (Fig. 17.2).

FIGURE 17.2 Father and mother looking at their newborn after birth. Note the newborn’s hat and warm blanket to preserve body heat.

Heat Loss Newborns have several characteristics that predispose them to heat loss: • Thin skin with blood vessels close to the surface • Lack of shivering ability to produce heat until 3 months old • Limited stores of metabolic substrates (glucose, glycogen, fat) • Limited use of voluntary muscle activity or movement to produce heat • Large body surface area relative to body weight • Lack of subcutaneous fat, which provides insulation • Little ability to conserve heat by changing posture (fetal position) • No ability to adjust their own clothing or blankets to achieve warmth • Inability to communicate that they are too cold or too warm

EVIDENCE-BASED PRACTICE 17.1 EFFECT OF EARLY MATERNAL/NEWBORN SKIN-TO-SKIN CONTACT AFTER BIRTH ON THE DURATION OF THIRD STAGE OF LABOR AND INITIATION OF BREAST-FEEDING

STUDY The holding of a newborn with vertical skin-to-skin contact typically in an upright position with the swaddled newborn on the chest of the mother, is commonly referred to as kangaroo care. It has been recommended that this skin-to-skin contact is a feasible, natural, and cost-effective intervention for breast-feeding initiation and thermoregulation. The aim of this study was to determine the effect of early maternal–newborn skin-to-skin contact after birth on the duration of the third stage of labor and initiation of breastfeeding.

Findings A nonrandomized controlled clinical trial was conducted using a sample of 100 laboring women. The project included a study group (50) who had skinto-skin contact and a control group (50) who received routine hospital care. Tools used to collect data included a structured interview, assessment of mothers during the third stage of labor, and an outcome assessment of first breast-feeding. The results revealed that success in first-time breast-feeding during the complete separation of the placenta and immediate contraction of the uterus was higher in the study group compared to the control group. There were statistically significant differences between the study and control groups in third stage of labor duration (9 minutes shorter), complete placental separation, and immediate contraction of the uterus or excessive bleeding. The study concluded that mothers who practice early mother/newborn skinto-skin contact immediately after giving birth experienced a shorter third stage duration and early successful initiation of breast-feeding.

Nursing Implications Based on these findings, it would make sense to incorporate early skin-to-skin contact immediately post birth and delay routine infant care until the success of the first breast-feeding process for the benefits it provides both mother and newborn. Nurses need to apply evidence-based research into their care since this application would improve maternal and child health outcomes. Adapted from Essa, R. M., & Ismail, N. I. Effect of early maternal/newborn skin-to-skin contact after birth on the duration of third stage of labor and initiation of breastfeeding. Journal of Nursing Education and Practice, 5(4), 98–107.

Every newborn struggles to maintain body temperature from the moment of birth, when the newborn’s wet body is exposed to the much cooler environment of the birthing room. The amniotic fluid covering the newborn cools as it evaporates rapidly in the low humidity and air conditioning of the room. The newborn’s temperature may decrease 3 to 5 degrees within minutes after leaving the warmth of the mother’s uterus (99.6°F [37.5°C]). The skin of newborns adjusts quickly to the challenging environmental conditions of extrauterine life. However, certain functions, for example, microcirculation, continue to develop even beyond the neonatal period (McCall et al., 2014).

Consider This

When I look down at my little miracle of life in my arms, I can’t help but beam with pride at this great accomplishment. She seems so vulnerable and defenseless, and yet is equipped with everything she needs to survive at birth. When the nurse brought my daughter in for the first time after birth, I wanted to see and feel every part of her. Much to my dismay, she was wrapped up like a mummy in a blanket and she had a pink knit cap on her head. I asked the nurse why all the babies had to look like they were bound for the North Pole with all these layers on. Wasn’t the nurse aware it was summertime and

probably at least 85 degrees outside? The nurse explained that newborns lose body heat easily and need to be kept warm until their temperature stabilizes. Even though I wanted to get up close and personal with my baby, I decided to keep the pink polar bear outfit on her. Thoughts: Newborns may be born with “everything they need to survive” on the outside, but they still experience temperature instability and lose heat through radiation, evaporation, convection, and conduction. Because the newborn’s head is the largest body part, a great deal of heat can be lost if a cap is not kept on the head. What guidance can be given to this mother before discharge to stabilize her daughter’s temperature while at home? What simple examples can be used to demonstrate your point? The transfer of heat depends on the temperature of the environment, air speed, and water vapor pressure or humidity. Heat exchange between the environment and the newborn involves the same mechanisms as those with any physical object and its environment. Heat can be lost by four mechanisms including conduction (3%), convection (34%), evaporation (24%), and radiation (39%) (Sharma et al., 2014). Prevention of heat loss is a key nursing intervention (Fig. 17.3). CONDUCTION Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with each other. Conduction refers to heat fluctuation between the newborn’s body surface when in contact with other solid surfaces, such as a cold mattress, scale, or circumcision restraining board. Heat loss by conduction can also occur when touching a newborn with cold hands or when the newborn has direct contact with a colder object such as a metal scale. Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps to prevent heat loss through conduction. Placing the newborn skin-to-skin with the mother also helps prevent heat loss through conduction. CONVECTION Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. An example of

convection-related heat loss would be a cool breeze that flows over the newborn. To prevent heat loss by this mechanism, keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Using clothing and blankets in isolettes is an effective means of reducing the newborn’s exposed surface area and providing external insulation. Also, transporting the newborn to the nursery in a warmed isolette, rather than carrying him or her, helps to maintain warmth and reduce exposure to the cool air. EVAPORATION Evaporation involves the loss of heat when a liquid is converted to vapor. Evaporative loss may be insensible (such as from skin and respiration) or sensible (such as from sweating). Insensible loss occurs, but the individual is not aware of it. Sensible loss is objective and can be noticed. It depends on air speed and the absolute humidity of the air. For example, when the baby is born, the body is covered with amniotic fluid. The fluid evaporates into the air, leading to heat loss. Heat loss via evaporation also occurs when bathing a newborn. Drying newborns immediately after birth with warmed blankets and placing a cap on their head will help to prevent heat loss through evaporation. In addition, drying the newborn after bathing will help prevent heat loss through evaporation. Promptly changing wet linens, clothes, or diapers will also reduce heat loss and prevent chilling.

FIGURE 17.3 The four mechanisms of heat loss in the newborn. A. Conduction. B. Convection. C. Evaporation. D. Radiation.

RADIATION Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. The amount of heat loss

depends on the size of the cold surface area, the surface temperature of the newborn’s body, and the temperature of the receiving surface area. For example, when a newborn is placed in a single-wall isolette next to a cold window, heat loss from radiation occurs. Newborns will become cold even though they are in a heated isolette. To reduce heat loss by radiation, keep cribs and isolettes away from outside walls, cold windows, and air conditioners. Also, using radiant warmers for transporting newborns and when performing procedures that may expose the newborn to the cooler environment will help reduce heat loss. A warmed transporter is an enclosed isolette on wheels. A radiant warmer is an open bed with a radiant heat source above. This type of environment allows health care providers to reach the newborn to carry out procedures and treatments.

Overheating The newborn is also prone to overheating. Limited insulation and limited sweating ability can predispose any newborn to overheating. Control of body temperature is achieved via a complex negative feedback system that creates a balance between heat production, heat gain, and heat loss. The primary heat regulator is located in the hypothalamus and the central nervous system. The immaturity of the newborn’s central nervous system makes it difficult to create and maintain this balance. Therefore, the newborn can become overheated easily. For example, an isolette that is too warm or one that is left too close to a sunny window may lead to hyperthermia. Although heat production can substantially increase in response to a cool environment, basal metabolic rate and the resultant heat produced cannot be reduced. Overheating increases fluid loss, the respiratory rate, and the metabolic rate considerably.

Thermoregulation Humans have the ability to regulate their body temperature within a narrow range. Newborns have a decreased ability to regulate their body temperature, producing heat through nonshivering thermogenesis. Thermoregulation, the balance between heat loss and heat production, is related to the newborn’s rate of metabolism and oxygen consumption. The newborn attempts to conserve heat and increase heat production by increasing the metabolic rate, increasing muscular activity through movement, increasing peripheral vasoconstriction, and assuming a fetal position to hold in heat and minimize exposed body surface

area. Concept Mastery Alert Effects of Cold Stress in the Newborn’s Brown Fat Metabolism The newborn first experiences an increase in norepinephrine in response to a cold environment. This then influences the triglycerides to stimulate brown fat metabolism.

An environment in which body temperature is maintained without an increase in metabolic rate or oxygen use is called a neutral thermal environment. Within a neutral thermal environment, the rates of oxygen consumption and metabolism are minimal, and internal body temperature is maintained because of thermal balance. A neutral thermal environment promotes growth and stability, conserves energy for basic bodily functions, and minimizes heat (energy) and water loss (Knobel, 2014). Because newborns have difficulty maintaining their body heat through shivering or other mechanisms, they need a higher environmental temperature to maintain a neutral thermal environment. If the environmental temperature decreases, the newborn responds by consuming more oxygen. The respiratory rate increases (tachypnea) in response to the increased need for oxygen. As a result the newborn’s metabolic rate increases. As noted earlier, the newborn’s primary method of heat production is through nonshivering thermogenesis. This is a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Brown fat is a special kind of highly vascular fat found only in newborns. Brown adipose tissue is a unique tissue that is able to convert chemical energy directly into heat when activated by the sympathetic nervous system. It is produced during the third trimester; ordinarily disappears by 3 to 5 weeks after birth and is vital for thermogenesis. The brown coloring is derived from the fat’s rich supply of blood vessels and nerve endings. These fat deposits, which are capable of intense metabolic activity—and thus can generate a great deal of heat—are found between the scapulae, axillae, at the nape of the neck, in the mediastinum, and in areas surrounding the kidneys and adrenal glands. Brown fat makes up about 6% of

term body weight in the full-term newborn (Betz & Enerback, 2015). When the newborn experiences a cold environment, norepinephrine is released. This in turn stimulates brown fat metabolism by breaking down triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat (Fig. 17.4). Newborns can experience heat loss through all four mechanisms, ultimately resulting in cold stress. Cold stress is excessive heat loss that requires a newborn to use compensatory mechanisms (such as nonshivering thermogenesis and tachypnea) to maintain core body temperature (Davidson, 2014). The consequences of cold stress can be quite severe. As the body temperature decreases, the newborn becomes less active, lethargic, hypotonic, and weaker. All newborns are at risk for cold stress, particularly within the first 12 hours of life. However, preterm newborns are at the greatest risk for cold stress and experience more profound effects than full-term newborns because they have fewer fat stores, poorer vasomotor responses, and less insulation to cope with a hypothermic event.

FIGURE 17.4 Areas of brown fat in a newborn.

Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production (Mattson & Smith, 2015).

Take Note! Nurses must be aware of the thermoregulatory needs of the newborn and must ensure that these needs are met to provide the newborn with the best start possible. Maintenance of temperature stability should be focused on preventative measures. To minimize the effects of cold stress and maintain an NTE, the following interventions are helpful: • Prewarming blankets and hats to reduce heat loss through conduction • Keeping the infant transporter (warmed isolette) fully charged and heated at all times • Drying the newborn completely after birth to prevent heat loss from evaporation • Encouraging skin-to-skin contact with the mother if the newborn is stable • Promoting early breast-feeding to provide fuels for nonshivering thermogenesis • Using heated and humidified oxygen • Always using radiant warmers and double-wall isolettes to prevent heat loss from radiation • Deferring bathing until the newborn is medically stable, and using a radiant heat source while bathing (Fig. 17.5) • Avoiding the placement of a skin temperature probe over a bony area or one with brown fat, because it does not give an accurate assessment of the whole body temperature (most temperature probes are placed over the liver when the newborn is supine or side-lying)

FIGURE 17.5 Bathing a newborn under a radiant warmer to prevent heat loss.

The preceding interventions allow the newborn to minimize his or her metabolic rate and oxygen consumption, thereby conserving vital energy stores required for optimum growth.

Hepatic System Function The liver has an essential role in the synthesis, degradation, and regulation of pathways involved in the metabolism of carbohydrates, proteins, lipids, trace elements, and vitamins. At birth, the newborn’s liver slowly assumes the functions that the placenta handled during fetal life. Most enzymatic pathways are present in the newborn, but are inactive at birth and generally become fully active at 3 months of age. These functions include blood coagulation, and also iron storage, carbohydrate metabolism, and conjugation of bilirubin, as discussed next. Glycogen reserves provide energy and may become depleted if the metabolic needs of the newborn increase, such as during cold or respiratory stress.

Iron Storage As red blood cells are destroyed after birth, their iron is released and stored by the liver until new red cells need to be produced. Newborn iron stores are determined by total body hemoglobin content and length of gestation. If the mother’s iron intake was adequate during pregnancy, sufficient iron has been stored in the newborn’s liver for use during the first 6 months of age.

Carbohydrate Metabolism Glucose is an essential fuel for brain metabolism. When the placenta is lost at birth, the maternal glucose supply is cut off. Initially, the newborn’s serum glucose levels decline. Newborns must learn to regulate their blood glucose concentration and adjust to an intermittent feeding schedule. Usually, a term newborn’s blood glucose level is 70% to 80% of the maternal blood glucose level at birth. Hypoglycemia is one of the most frequent problems encountered, and maintaining glucose homeostasis is one of the important physiologic events during the fetal-to-newborn transition. During the first 24 to 48 hours of life, as normal neonates transition from intrauterine to extrauterine life, their plasma glucose levels are usually lower than later in life (Thornton et al., 2015). Glucose is the main source of energy for the first several hours after birth. With the newborn’s increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Initiating early breast-feeding or bottle feeding helps to stabilize the newborn’s blood glucose levels. No evidence

supports universal invasive routine measurement of glucose in healthy term newborns. Selective screening of at-risk newborns is more appropriate (Adamkin, 2015).

Bilirubin Conjugation The liver is also responsible for the conjugation of bilirubin—a yellow-to-orange bile pigment produced by the breakdown of red blood cells. In utero, elimination of bilirubin in the blood is handled by the placenta and the mother’s liver. However, once the cord is cut, the newborn must now assume this function. Bilirubin normally circulates in plasma, is taken up by liver cells, and is changed to a water-soluble pigment that is excreted in the bile. This conjugated form of bilirubin is excreted from liver cells as a constituent of bile. The principal source of bilirubin in the newborn is the hemolysis of erythrocytes. This is a normal occurrence after birth, when fewer red blood cells are needed to maintain extrauterine life. When red blood cells die after approximately 80 days of life, the heme in their hemoglobin is converted to bilirubin. Bilirubin is released in an unconjugated form called indirect bilirubin, which is fat soluble. Enzymes, proteins, and different cells in the reticuloendothelial system and liver process the unconjugated bilirubin into conjugated bilirubin or direct bilirubin. This form is water soluble and now enters the gastrointestinal system via the bile and is eventually excreted through feces. The kidneys also excrete a small amount. Newborns produce bilirubin at a rate of approximately 6 to 8 mg/kg/day. This is more than twice the production rate in adults, primarily because of relative polycythemia and increased red blood cell turnover. Bilirubin production typically declines to the adult level within 10 to 14 days after birth (Bhutani et al., 2015). In addition, the metabolic pathways of the liver are relatively immature and thus cannot conjugate bilirubin as quickly as needed. Failure of the liver cells to break down and excrete bilirubin can cause an increased amount of bilirubin in the bloodstream, leading to jaundice (Sharma et al., 2014). Bilirubin is toxic to the body and must be excreted. Blood tests ordered to determine bilirubin levels measure bilirubin in the serum. Total bilirubin is a combination of indirect (unconjugated) and direct (conjugated) bilirubin. When unconjugated bilirubin pigment is deposited in the skin and mucous membranes as a result of increased bilirubin levels, jaundice, also known as icterus, develops, with a yellowing of the skin, sclera, and mucous

membranes. Visible jaundice as a result of increased blood bilirubin levels occurs in more than half of all healthy newborns. Even in healthy term newborns, extremely elevated blood levels of bilirubin during the first week of life can cause bilirubin encephalopathy, a permanent and devastating form of brain damage (Wong & Bhutani, 2015). Common risk factors for the development of jaundice include fetal–maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breast-feeding, drugs (such as diazepam [Valium], oxytocin [Pitocin], sulfisoxazole/erythromycin [Pediazole], and chloramphenicol [Chloromycetin]), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth, resulting in cephalhematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, intrauterine infections such as TORCH (toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes simplex viruses), and ethnicity such as Asian or Native American (Moses, 2015). The causes of newborn jaundice can be classified into three groups based on the mechanism of accumulation: 1. Bilirubin overproduction, such as from blood incompatibility (Rh or ABO), drugs, trauma at birth, polycythemia, delayed cord clamping, and breast milk jaundice 2. Decreased bilirubin conjugation, as seen in physiologic jaundice, hypothyroidism, and breast-feeding 3. Impaired bilirubin excretion, as seen in biliary obstruction (biliary atresia, gallstones, neoplasm), sepsis, hepatitis, chromosomal abnormality (Turner syndrome, trisomies 18 and 21), and drugs (aspirin, acetaminophen, sulfa, alcohol, steroids, antibiotics) (Nagtalon-Ramos, 2014) Jaundice in the newborn is discussed in more detail in Chapter 24.

Gastrointestinal System Adaptations The full-term newborn has the capacity to swallow, digest, metabolize, and absorb food taken in soon after birth. At birth, the pH of the stomach contents is mildly acidic, reflecting the pH of the amniotic fluid. The once-sterile gut changes rapidly, depending on what feeding is received. Bowel sounds are normally heard shortly after birth, but may be hypoactive on the first day.

Mucosal Barrier Protection Humans start their development in a sterile intrauterine environment, but from the very moment of birth all epithelial surfaces in direct contact with the environment (skin, respiratory, gastrointestinal, and urogenital tract) are colonized by microorganisms. An important adaptation of the gastrointestinal system is the development of a mucosal barrier to prevent the penetration of harmful substances (bacteria, toxins, and antigens) present within the intestinal lumen. At birth, the newborn must be prepared to deal with bacterial colonization of the gut. Colonization is dependent on oral intake. Nutrition, be it breast milk or formula, plays a major role in early colonization patterns in the neonatal gut. It usually occurs within 24 hours of age and is required for the production of vitamin K (Gritz & Bhandari, 2015). After birth, environmental, oral, and cutaneous microbes from the mother will be mechanically transferred to the newborn by several processes including suckling, kissing, and caressing. Thus, the proximity of the birth canal and the anus, as well as parental expression of neonatal care, are effective methods of ensuring transmission of microbes from one generation to the next. If harmful substances are allowed to penetrate the mucosal epithelial barrier under pathologic conditions, they can cause inflammatory and allergic reactions (Nylund et al., 2014).

Take Note! Human breast milk provides a passive mechanism to protect the newborn against the dangers of a deficient intestinal defense system. It contains antibodies, viable leukocytes, and many other substances that can interfere with bacterial colonization and prevent harmful penetration.

Stomach and Digestion The newborn must rapidly adapt from receiving all nutrient and energy requirements via the placenta to obtaining them orally after birth. The physiologic capacity of the newborn stomach is considerably less than its anatomic capacity. There is a rapid gain in physiologic capacity during the first 4 days of life. After the first 4 days, the anatomic and physiologic capacities more closely approximate each other. Researchers have found that for the first 24 hours after birth, the newborn’s small stomach does not stretch to hold more, as it will within a day or two later (Batchelor, 2014). This explains the experience of countless hospital nurses who have learned the hard way that when newborns are fed an ounce or two by bottle during the first day of life, most of it tends to come right back up. The walls of the newborn stomach stay firm, expelling extra milk rather than stretching to hold it. For bottle-fed newborns, small, frequent feedings set up a healthy eating pattern right from the start (breast-fed newborns self-regulate how much they consume). Experts now advise adults that it is healthier to eat smaller amounts more often and the same is true for babies and children. Coaxing an infant to take more milk leads to overfeeding. If feeling overfull at feedings becomes the norm for a young infant, this may lead to unhealthy eating habits that contribute to childhood and adult obesity later. Early onset obesity is a precursor to a lifelong weight struggle and numerous comorbidities (Redsell et al., 2015; Reilly & Hughes, 2015). The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves also contribute to the reflux of gastric contents. Avoiding overfeeding and stimulating frequent burping may minimize regurgitation. Most digestive enzymes are available at birth, allowing newborns to digest simple carbohydrates and protein. However, they have limited ability to digest complex carbohydrates and fats, because amylase and lipase levels are low at birth. As a result, newborns excrete a fair amount of lipids, resulting in fatty stools. Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. To gain

weight, the term newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age. Understanding the role and importance of nutrition in early postnatal life on growth and development is vital, but how it links to later health has the potential of health benefits for all future generations (Robinson, 2015).

Bowel Elimination The frequency, consistency, and type of stool passed by newborns vary widely. The evolution of a stool pattern begins with a newborn’s first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semisterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breast-fed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The frequency of bowel movements varies widely from one infant to another.

Take Note! Newborns that are fed early pass stools sooner, which helps to reduce bilirubin buildup (Mattson & Smith, 2015). The last development in the stool pattern is the milk stool. Its characteristics differ in breast-fed and formula-fed newborns. The stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

Renal System Changes A full complement of one million nephrons is present by 34 weeks gestation. The glomeruli and nephrons are functionally immature at birth, resulting in a reduced glomerular filtration rate (GFR) and limited concentrating ability. A limited ability to concentrate urine and the reduced GFR make the newborn susceptible to both dehydration and fluid overload (Sharma et al., 2014). Frequently the newborn’s kidneys are described as immature, but they are able to carry out their usual responsibilities and can handle the challenge of excretion and maintaining acid–base balance. Only when the newborn is faced with unexpected imbalances of water, electrolytes, or a disruption of acid–base status secondary to a preterm birth or illness does it lack the ability to handle the body’s fluid homeostasis. A newborn infant’s body mass is 75% water, the highest proportion of body water at any stage of a person’s life. The majority of term newborns void immediately after birth, indicating adequate renal function. Although the newborn’s kidneys can produce urine, they are limited in their ability to concentrate it until about 3 months of age, when the kidneys mature more. Until that time, a newborn voids frequently and the urine has a low specific gravity (1.001 to 1.020). About six to eight voidings daily is average for most newborns; this indicates adequate fluid intake (Harshman & Brophy, 2014). The renal cortex is relatively underdeveloped at birth and does not reach maturity until 12 to 18 months of age. The GFR is the amount of fluid filtered each minute by all the glomeruli of both kidneys and is one index of kidney function. At birth, the newborn’s GFR is approximately 30% of normal adult values, reaching approximately 50% of normal adult values by the 10th day of life and full adult values by the first year of life (Chishti, 2014). The low GFR and the limited excretion and conservation capability of the kidney affect the newborn’s ability to excrete salt, water loads, and drugs.

Take Note! The possibility of fluid overload is increased in newborns; keep this in mind when administering intravenous therapy to a newborn.

Immune System Adaptations Essential to the newborn’s survival is the ability to respond effectively to hostile environmental forces. The newborn’s immune system begins working early in gestation, but many of the responses do not function adequately during the early neonatal period. The newborn is protected from certain infections, in part because of maternal antibodies circulating in their system until about 6 months of age. Immunoglobulin G (IgG) crosses the placenta to the fetus while in utero. Newborns who are breast-fed receive antibodies from the breast milk, which includes IgE, IgA, IgM, and IgG (Nagtalon-Ramos, 2014). The risk of acquiring an infection is great because a newborn’s immune system is immature and is not able to respond for long periods of time to fight infections. The intrauterine environment usually protects the fetus from harmful microorganisms and the need for defensive immunologic responses. With exposure to a wide variety of microorganisms at birth, the newborn must develop a balance between its host defenses and the hostile environmental organisms to ensure a safe transition to the outside world. Healthy infants begin to produce their own antibodies, starting at 2 to 3 months of age. Responses of the immune system serve three purposes: defense (protection from invading organisms), homeostasis (elimination of worn-out host cells), and surveillance (recognition and removal of enemy cells). The newborn’s immune system response involves recognition of the pathogen or other foreign material, followed by activation of mechanisms to react against and eliminate it. All immune responses primarily involve leukocytes (white blood cells). The immune system’s responses can be divided into two categories: natural and acquired immunity. These mechanisms are interrelated and interdependent; both are required for immunocompetency.

Natural Immunity Natural immunity includes responses or mechanisms that do not require previous exposure to the microorganism or antigen to operate efficiently. Physical barriers (such as intact skin and mucous membranes), chemical barriers (such as gastric acids and digestive enzymes), and resident nonpathologic organisms make up the newborn’s natural immune system. Natural immunity involves the most basic host defense responses: ingestion and killing of microorganisms by phagocytic

cells.

Acquired Immunity Acquired immunity involves two primary processes: (1) the development of circulating antibodies or immunoglobulins capable of targeting specific invading agents (antigens) for destruction and (2) formation of activated lymphocytes designed to destroy foreign invaders. Acquired immunity is absent until after the first invasion by a foreign organism or toxin. Immunologic ability depends heavily on immunoglobulins such as IgG, IgM, and IgA. The newborn depends largely on these three immunoglobulins for defense against microorganisms associated with illness. Newborns remain very susceptible to infections for months. IgG is the major immunoglobulin and the most abundant, making up about 80% of all circulating antibodies (Martin, Fanaroff, & Walsh, 2014). It is found in serum and interstitial fluid. It is the only class able to cross the placenta, with active placental transfer beginning at approximately 20 to 22 weeks’ gestation. IgG produces antibodies against bacteria, bacterial toxins, and viral agents. IgA is the second most abundant immunoglobulin in the serum. IgA does not cross the placenta, and maximum levels are reached during childhood. This immunoglobulin is believed to protect mucous membranes from viruses and bacteria. IgA is predominantly found in the gastrointestinal and respiratory tracts, tears, saliva, colostrum, and breast milk.

Take Note! A major source of IgA is human breast milk, so breast-feeding is believed to have significant immunologic advantages over formula feeding (Walker, 2014). IgM is found in blood and lymph fluid and is the first immunoglobulin to respond to infection. It does not cross the placenta, and levels are generally low at birth unless a congenital intrauterine infection is present. IgM offers a major source of protection from blood-borne infections. The predominant antibodies formed during neonatal or intrauterine infection are of this class.

Integumentary System Adaptations The newborn skin is critical to its transition from intrauterine to extrauterine environments and to the journey to self-sufficiency. The newborn’s skin is a large organ, making up approximately 13% of body weight in contrast to 3% of body weight in an adult. It is sensitive, fragile, with a neutral pH on the surface, lower lipid content, and higher water content when compared with adults. Because of these characteristics, newborn skin is vulnerable to injury and infections (Visscher, et al., 2015). The most important function of the skin is to provide a protective barrier between the body and the environment. It limits the loss of water, prevents absorption of harmful agents, protects thermoregulation and fat storage, and protects against physical trauma. The epidermal barrier begins to develop during midgestation and is fully formed by about 32 weeks’ gestation. Although the neonatal epidermis is similar to the adult epidermis in thickness and lipid composition, skin development is not complete at birth (King et al., 2015). Although the basic structure is the same as that of an adult, the less mature the newborn, the less mature the skin functions. Fewer fibrils connect the dermis and epidermis in the newborn compared with the adult. Also in a newborn, the risk of injury producing a break in the skin from the use of tapes and monitors and from handling is greater than for an adult. Improper handling of the newborn during daily skin care practices, such as bathing, can cause damage, prevent healing, and interfere with the normal maturation process. Newborns vary greatly in appearance. Many of the variations are temporary and reflect the physiologic adaptations that the newborn is experiencing. Skin coloring varies, depending on the newborn’s age, race, or ethnic group; temperature; and whether he or she is crying. Skin color changes with both the environment and health status. At birth, the newborn’s skin is dark red to purple. As the newborn begins to breathe air his or her skin color changes to red. This redness normally begins to fade the first day.

Neurologic System Adaptations The nervous system is immature and continues to develop to achieve a full complement of cortical and brainstem cells by 1 year of age. The brain increases its size threefold during the first year of life. The nervous system consists of the brain, spinal cord, 12 cranial nerves, and a variety of spinal nerves that come from the spinal cord. Neurologic development follows cephalocaudal (head-totoe) and proximal–distal (center-to-outside) patterns. Myelin develops early on in sensory impulse transmitters. Thus, the newborn has an acute sense of hearing, smell, and taste. The newborn’s sensory capabilities include: • Hearing—well developed at birth, responds to noise by turning to sound. • Taste—ability to distinguish between sweet and sour by 72 hours old. • Smell—ability to distinguish between mother’s breast milk and breast milk from others. • Touch—sensitivity to pain, responds to tactile stimuli. • Vision—is incomplete at birth. Maturation is dependent on nutrition and visual stimulation. Newborns have ability to focus only on close objects (8 to 10 inches away) with a visual acuity of 20/140; they can track objects in midline or beyond (90 inches). This is the least mature sense at birth. The ability to fix, follow, and be alert is indicative of an intact CNS (King et al., 2015). Remember Maria, the new mother who is worried that her daughter can’t see? What might the new mother notice about her daughter’s behavior? What might be the new mother’s expectations?

Congenital Reflexes Successful adaptations demonstrated by the respiratory, circulatory, thermoregulatory, and musculoskeletal systems indirectly indicate the central nervous system’s successful transition from fetal to extrauterine life, because the central nervous system plays a major role in all these adaptations. In the newborn, congenital reflexes are the hallmarks of maturity of the central nervous system, viability, and adaptation to extrauterine life. The presence and strength of a reflex is an important indication of neurologic

development and function. A reflex is an involuntary muscular response to a sensory stimulus. It is built into the nervous system and does not need the intervention of conscious thought to take effect. The physical assessment of the neurologic system of the newborn includes evaluating the major reflexes (gag, Babinski, Moro, and Galant) and minor ones (finger grasp, toe grasp, rooting, sucking, head righting, stepping, and tonic neck). To assess each reflex, the nurse progresses methodically, taking care to document each finding (Weber & Kelly, 2014). Many neonatal reflexes disappear with maturation, although some remain throughout adulthood. The arcs of these reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor systems. The ways newborns blink, move their limbs, focus on a caretaker’s face, turn toward sound, suck, swallow, and respond to the environment are all indications of their neurologic abilities. Congenital defects within the central nervous system are frequently not overt but may be revealed in abnormalities in tone, posture, or behavior (Davidson, 2014). Damage to the nervous system (birth trauma, perinatal hypoxia) during the birthing process can cause delays in the normal growth, development, and functioning of the newborn. Early identification may help to identify the cause and to start early intervention to decrease long-term complications or permanent sequelae. Newborn reflexes are assessed to evaluate neurologic function and development. Absent or abnormal reflexes in a newborn, persistence of a reflex past the age when it is normally lost, or redevelopment of an infantile reflex in an older child or adult may indicate neurologic pathology. (See Chapter 18 for a description of newborn reflex assessment.) The Healthy Start nurse explained to Maria that all newborns are born with some degree of myopia (inability to see distances) and that 20/20 vision is not generally achieved until 2 years of age. What developmental information should the nurse discuss with Maria?

BEHAVIORAL ADAPTATIONS In addition to adapting physiologically, the newborn also adapts behaviorally. All newborns progress through a specific pattern of events after birth, regardless of their gestational age or the type of birth they experienced.

Behavioral Patterns The newborn usually demonstrates a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity separated by a sleep phase. Behavioral adaptation is a defined progression of events triggered by stimuli from the extrauterine environment after birth.

FIGURE 17.6 The first period of reactivity is an optimal time for interaction.

First Period of Reactivity The first period of reactivity begins at birth and may last from 30 minutes up to 2 hours. The newborn is alert and moving and may appear hungry. This period is characterized by myoclonic movements of the eyes, spontaneous Moro reflexes, sucking motions, chewing, rooting, and fine tremors of the extremities. Muscle tone and motor activity are increased (Healy & Fallon, 2014). Respiration and heart rate are elevated but gradually begin to slow as the next period begins. This period of alertness allows parents to interact with their newborn and to enjoy close contact with their new baby (Fig. 17.6). The appearance of sucking and rooting behaviors provides a good opportunity for initiating breast-feeding. Many newborns latch on the nipple and suck well at this first experience.

Period of Decreased Responsiveness At 30 to 120 minutes of age, the newborn enters the second stage of transition—

that of the sleep period or a decrease in activity. This phase is referred to as a period of decreased responsiveness. Movements are less jerky and less frequent. Heart and respiratory rates decline as the newborn enters the sleep phase. The muscles become relaxed, and responsiveness to outside stimuli diminishes. During this phase, it is difficult to arouse or interact with the newborn. No interest in sucking is shown. This quiet time can be used for both mother and newborn to remain close and rest together after labor and the birthing experience.

Second Period of Reactivity The second period of reactivity begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Davidson, 2014). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination (Fig. 17.7).

FIGURE 17.7 Newborn during the second period of reactivity. Note the newborn’s wide-eyed interest.

Interaction between the mother and the newborn during this second period of reactivity is encouraged if the mother has rested and desires it. This period also provides a good opportunity for the parents to examine their newborn and ask questions.

Take Note! Teaching about feeding, positioning for feeding, and diaper-changing techniques can be reinforced during this time.

Behavioral Responses Newborn development is a reflection of the dynamic relationship between endowment and environment. Newborns demonstrate several predictable responses when interacting with their environment. How they react to the world around them is termed a neurobehavioral response. It comprises predictable periods that are probably triggered by external stimuli. Expected newborn behaviors include orientation, habituation, motor maturity, self-quieting ability, and social behaviors. Any deviation in behavioral responses requires further assessment, because it may indicate a complex neurobehavioral problem.

Orientation The response of newborns to stimuli is called orientation. They become more alert when they sense a new stimulus in their environment. Orientation reflects newborns’ response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Newborns prefer the human face and bright shiny objects. As the face or object comes into their line of vision, newborns respond by staring at the object intently. Newborns use this sensory capacity to become familiar with people and objects in their surroundings. Remember Maria, who was concerned about her newborn daughter’s vision? She told the nurse that her daughter did not show any interest in her pastelcolored homemade mobile she had hung across the room from her crib. What suggestions can the nurse make to Maria regarding the placement of the mobile and the types and colors of objects used to promote orientation in her newborn daughter?

Habituation Habituation is the newborn’s ability to process and respond to visual and auditory stimuli. It is a measure of how well and appropriately an infant responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. During the first 24 hours after birth, newborns should increase their ability to habituate to

environmental stimuli and sleep. Habituation provides a useful indicator of their neurobehavioral intactness.

Motor Maturity Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Bringing the hand up to the mouth is an example of good motor organization. As newborns adapt to their new environment, smoother movements should be observed. Such motor behavior is a good indicator of the newborn’s ability to respond and adapt accordingly; it indicates that the central nervous system is processing stimuli appropriately.

Self-Quieting Ability Self-quieting ability (also called self-soothing) refers to newborns’ ability to quiet and comfort themselves. Newborns vary in their ability to console themselves or to be consoled. “Consolability” is how newborns are able to change from the crying state to an active alert, quiet alert, drowsy, or sleep state. They console themselves by hand-to-mouth movements and sucking, alerting to external stimuli, and motor activity (Karp, 2014). Recent research outlines five things (the five “S’s”) that parents can do to calm a fussy infant: 1. Swaddling tightly 2. Side/stomach position on the lap of the caretaker 3. Shushing loudly or continuous white noise 4. Swinging using any rhythmic movement 5. Sucking (Karp, 2014) Assisting parents to identify consoling behaviors to quiet their newborn if the newborn is not able to self-quiet is important.

Social Behaviors Newborns begin extrauterine life able to engage in it with their sensory capabilities and communicate with their environment through a complex

repertoire of behaviors. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Usually newborns are very sensitive to being touched, cuddled, and held. Cuddliness is very important to parents because they frequently gauge their ability to care for their newborn by the newborn’s acceptance or positive response to their actions. This can be assessed by the degree to which the newborn nestles into the contours of the holder’s arms. Most newborns cuddle, but some will resist. Assisting parents to assume comforting behaviors (e.g., by cooing while holding their newborn) and praising them for their efforts can help foster cuddling behaviors. KEY CONCEPTS The neonatal period is defined as the first 28 days of life. As the newborn adapts to life after birth, numerous physiologic changes occur. At birth, the cardiopulmonary system must switch from fetal to neonatal circulation and from placental to pulmonary gas exchange. One of the most crucial adaptations that the newborn makes at birth is the adjustment of a fluid medium exchange from the placenta to the lungs and that of a gaseous environment. Neonatal red blood cells have a life span of 80 to 100 days in comparison with the adult red blood cell life span of 120 days. This difference in red blood cell life span causes several adjustment problems. Thermoregulation is the maintenance of balance between heat loss and heat production. It is a critical physiologic function that is closely related to the transition and survival of the newborn. The newborn’s primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Brown fat is a special kind of highly vascular fat found only in newborns. Heat loss in the newborn is the result of four mechanisms: conduction, convection, evaporation, and radiation. Responses of the immune system serve three purposes: defense (protection from invading organisms), homeostasis (elimination of worn-out host cells), and surveillance (recognition and removal of enemy cells). In the newborn, congenital reflexes are the hallmarks of maturity of the CNS,

viability, and adaptation to extrauterine life. The newborn usually demonstrates a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity separated by a sleep phase.

References and Recommended Readings Adamkin, D. H. (2015). Metabolic screening and postnatal glucose homeostasis in the newborn. Pediatric Clinics of North America, 62(2), 385–409. American Academy of Pediatrics [AAP]. (2013). Statement of endorsement: Timing of umbilical cord clamping after birth. Pediatrics, 131(4), e1323. American College of Obstetricians & Gynecologists [ACOG]. (2012). Committee Opinion No. 543: Timing of umbilical cord clamping after birth. Obstetrics & Gynecology, 120(6), 1522–1526. Andersson, O., Domellöf, M., Andersson, D., & Hellström-Westas, L. (2014). Effect of delayed vs early umbilical cord clamping on iron status and neurodevelopment at age 12 months: A randomized clinical trial. JAMA pediatrics, 168(6), 547–554. Batchelor, H. (2014). Pediatric development: Gastrointestinal. In Pediatric formulations (pp. 43–54). New York, NY: Springer. Betz, M. J., & Enerbäck, S. (2015). Human brown adipose tissue: What we have learned so far. Diabetes, 64(7), 2352–2360. Bhutani, V. K., Wong, R. J., Vreman, H. J., & Stevenson, D. K. (2015). Bilirubin production and hourspecific bilirubin levels. Journal of Perinatology, 35(9), 735–738. Bope, E. T., & Kellerman, R. D. (2015). Conn’s current therapy 2015. Philadelphia, PA: Elsevier. Chishti, A. S. (2014). Assessment of renal function. In Kidney and urinary tract diseases in the newborn (pp. 117–126). Berlin, Heidelberg, Germany: Springer. Creasy, R. K., Resnik, R., Iams, J. D., Lockwood, C. J., Moore, T. R., & Greene, M. F. (2014). Creasy & Resnik’s maternal-fetal medicine: Principles and practice (7th ed.). St. Louis, MO: Elsevier. Cuneo, B. (2014). Transition from fetal to neonatal circulation. In Pediatric and congenital cardiology, cardiac surgery and intensive care,(pp. 179–199). Berlin, Heidelberg, Germany: Springer. Davidson, M. R. (2014). Fast facts for the neonatal nurse: A nursing orientation and care guide in a nutshell. New York, NY: Springer. Essa, R. M., & Ismail, N. I. (2015). Effect of early maternal/newborn skin-to-skin contact after birth on the duration of third stage of labor and initiation of breastfeeding. Journal of Nursing Education and Practice, 5(4), 98–107. Fillipps, D. J., & Bucciarelli, R. L. (2015). Cardiac evaluation of the newborn. Pediatric Clinics of North America, 62(2), 471–489. Fischbach, F., & Dunning, M. B. (2014). Manual of laboratory and diagnostic tests (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Gritz, E. C., & Bhandari, V. (2015). The human neonatal gut microbiome: a brief review. Frontiers in Pediatrics, 3. 17–26.

Harshman, L. A., & Brophy, P. D. (2014). Development of renal function in the fetus and newborn. In Kidney and urinary tract diseases in the newborn (pp. 59–76). Berlin, Heidelberg, Germany: Springer. Healy, P., & Fallon, A. (2014). Developments in neonatal care and nursing responses. British Journal of Nursing, 23(1), 21–24. Hooper, S. B., Polglase, G. R., & Roehr, C. C. (2015). Cardiopulmonary changes with aeration of the newborn lung. Pediatric Respiratory Reviews, 16(3), 147–150. Karp, H. (2014). The happiest baby on the block. New York, NY: Bantam Dell. King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, MA: Jones & Bartlett Learning. Kluckow, M., & Hooper, S. B. (2015). Using physiology to guide time to cord clamping. Seminars in Fetal and Neonatal Medicine, 20(4), 225–231. Knobel, R. B. (2014). Fetal and neonatal thermal physiology. Newborn and Infant Nursing Reviews, 14(2), 45–49. Leslie, M. S. (2015). Perspectives on implementing delayed cord clamping. Nursing for Women’s Health, 19(2), 164–176. Martin, R. J., Fanaroff, A. A., & Walsh, M. C. (2014). Neonatal-perinatal medicine (10th ed.). Philadelphia, PA: Elsevier. Mattson, S., & Smith, J. (2015). Core curriculum for maternal-newborn nursing (5th ed.). Philadelphia, PA: Elsevier. McAdams, R. M. (2014). Time to implement delayed cord clamping. Obstetrics & Gynecology, 123(3), 549–552. McCall, E., Alderdice, F., Halliday, H., Johnston, L., & Vohra, S. (2014). Challenges of minimizing heat loss at birth: A narrative overview of evidence-based thermal care interventions. Newborn and Infant Nursing Reviews, 14(2), 56–63. Moses, S. (2015). Jaundice in newborns. Family Practice Notebook, Retrieved June 2015, from http://www.fpnotebook.com/NICU/GI/JndcInNwbrns.htm Nagtalon-Ramos, J. (2014). Maternal-newborn nursing care: Best evidence-based practices. Philadelphia, PA: F.A. Davis Company. Nylund, L., Satokari, R., Salminen, S., & de Vos, W. M. (2014). Intestinal microbiota during early life– impact on health and disease. Proceedings of the Nutrition Society, 73(04), 1–13. Redsell, S. A., Edmonds, B., Swift, J. A., Siriwardena, A. N., Weng, S., Nathan, D., et al. (2015). Systematic review of randomized controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood. Maternal & Child Nutrition, 12(1), 24–38. doi: 10.1111/mcn.12184 Reilly, J. J., & Hughes, A. R. (2015). Early life risk factors for childhood obesity. In L. Stewart & J. Thompson (Eds.), Early years nutrition and healthy weight (pp. 40–45). Hoboken, NJ: Wiley Blackwell

Publishers. Robinson, S. M. (2015). Infant nutrition and lifelong health: Current perspectives and future challenges. Journal of Developmental Origins of Health and Disease, 6(5), 384–389. Sharma, A., Ford, S., & Calvert, J. (2014). Adaptation for life: A review of neonatal physiology. Anesthesia & Intensive Care Medicine, 15(3), 89–95. Stave, U. (2014). Perinatal physiology. New York, NY: Springer. Stark, A. R., & Eichenwald, E. C. (2016). Persistent pulmonary hypertension of the newborn. UpToDate, Retrieved from http://www.uptodate.com/contents/persistent-pulmonary-hypertension-of-the-newborn Swanson, J. R., & Sinkin, R. A. (2015). Transition from fetus to newborn. Pediatric Clinics of North America, 62(2), 329–343. Thornton, P. S., Stanley, C. A., De Leon, D. D., Harris, D., Haymond, M. W., Hussain, K., et al. (2015). Recommendations from the Pediatric Endocrine Society for evaluation and management of persistent hypoglycemia in neonates, infants, and children. The Journal of Pediatrics, 167(2), 238–245. van Vonderen, J. J., Roest, A. A., Siew, M. L., Walther, F. J., Hooper, S. B., & te Pas, A. B. (2014). Measuring physiological changes during the transition to life after birth. Neonatology, 105(3), 230–242. Verklan, T., & Walden, M. (2014). Core curriculum for neonatal intensive care nursing (4th ed.). St. Louis, MO: Elsevier. Visscher, M. O., Adam, R., Brink, S., & Odio, M. (2015). Newborn infant skin: Physiology, development, and care. Clinics in Dermatology, 33(3), 271–280. Walker, M. (2014). Breastfeeding management for the clinician: Using the evidence (3rd ed.). Burlington, MA: Jones & Bartlett Learning. Weber, J., & Kelley, J. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Wong, R. J., & Bhutani, V. K. (2016). Clinical manifestations of unconjugated hyperbilirubinemia in term and late preterm infants. UpToDate, Retrieved May 2016, from: http://www.uptodate.com/contents/clinical-manifestations-of-unconjugated-hyperbilirubinemia-in-termand-late-preterm-infants World Health Organization [WHO]. (2014). Delayed clamping of the umbilical cord to reduce infant anemia (Doc. No. WHO/RHR/14.19 ed.). Geneva, Switzerland: Author.

CHAPTER WORKSHEET MULTIPLE-CHOICE QUESTIONS 1. When assessing the term newborn, the following are observed: newborn is

alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: a. Initial period of reactivity b. Second period of reactivity c. Decreased responsiveness period d. Sleep period for newborns 2. A nurse observes a 3-day-old term newborn that is starting to appear mildly jaundiced. What might explain this condition? a. Physiologic jaundice secondary to breast-feeding b. Hemolytic disease of the newborn due to blood incompatibility c. Exposing the newborn to high levels of oxygen d. Overfeeding the newborn with too much glucose water 3. After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? a. Transporting the newborn in an isolette b. Maintaining a warm room temperature c. Placing the newborn on a warmed surface d. Drying the newborn immediately after birth 4. After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? a. Foramen ovale b. Ductus arteriosus c. Ductus venosus d. Umbilical vein 5. Which of the following newborns could be described as breathing normally? a. Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm. b. Newborn B is breathing diaphragmatically with sternal retractions, at a rate

of 70 bpm. c. Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis. d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea. 6. When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate: a. Abnormal gastrointestinal newborn transition and needs to be reported b. An intestinal anomaly that needs immediate surgery c. A patent anus with no bowel obstruction and normal peristalsis d. A malabsorption syndrome, resulting in fatty stools 7. A nursing student questions the nursery nurse why they do not bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of: a. Jaundice b. Infection c. Hypothermia d. Anemia 8. Because the newborn’s red blood cells breakdown much sooner than those of an adult, what might result? a. Anemia b. Bruising c. Apnea d. Jaundice 9. The nurse performs a physical examination on a newborn 2 hours after birth. Which of the following findings indicate a need for a pediatric consultation? Select all that apply: a. Respiratory rate of 50 breaths per minute b. Intermittent episodes of apnea, lasting 2,500 g (>5.5 lb) • Very low birth weight: >1,500 g (>3.5 lb) • Extremely low birth weight: >1,000 g (>2.5 lb)

Vital Signs Heart rate and respiratory rate are assessed immediately after birth with Apgar scoring. Heart rate, obtained by taking an apical pulse for 1 full minute, typically is 110 to 160 bpm. Newborns’ respirations are assessed when they are quiet or sleeping. Place a stethoscope on the right side of the chest and count the breaths for 1 full minute to identify any irregularities. The newborn respiratory rate is 30 to 60 breaths/minute with symmetric chest movement. Heart and respiratory rates are usually assessed every 30 minutes until stable for 2 hours after birth. Once stable, the heart rate and respiratory rates are checked every 8 hours. These assessment time frames may vary per hospital protocols, so nurses should follow

the facility’s procedures (Nagtalon-Ramos, 2014).

FIGURE 18.2 Weighing the newborn. Note how the nurse guards the newborn with her hand to prevent falling.

Vital signs are assessed at birth, within 1 to 4 hours after birth according to hospital policy. Vital signs are used for identifying a variety of complications and for ensuring well-being of the newborn. In some health care agencies, temperatures are taken immediately after the Apgar score has been taken to allow for identification of hypothermia, which then requires a glucose check, but nurses need to follow their hospital protocols on this assessment timing. In term newborns, the normal axillary temperature range should be maintained at 97.7° to 99.5° F (36.5° to 37.5° C). Rectal temperatures are no longer taken because of the risk of perforation (AAP, 2015b). The thermometer or temperature probe is held in the midaxillary space according to manufacturer’s directions and hospital protocol. Blood pressure is not usually assessed as part of a normal newborn examination unless there is a clinical indication or low Apgar scores. If assessed, an oscillometer (Dinamap) is used. The typical range is 50 to 75 mm Hg (systolic) and 30 to 45 mm Hg (diastolic). Crying, moving, and late clamping of the umbilical cord will increase systolic pressure (Weber & Kelley, 2014). Typical values for newborn vital signs are provided in Table 18.2.

Gestational Age Assessment To determine a newborn’s gestational age (the stage of maturity), physical signs and neurologic characteristics are assessed. Typically, gestational age is determined by using a tool such as the Ballard gestational age assessment or Ballard Scale. It determines a newborn’s gestational age between 20 and 44 weeks. A score is assigned to the various parameters, and the total score

corresponds to a maturity rating in weeks of gestation (Fig. 18.3). This scoring system provides an objective estimate of gestational age by scoring the specific parameters of physical as well as neuromuscular maturity. Points are given for each assessment parameter, with a low score of –1 point or –2 points for extreme immaturity to 4 or 5 points for postmaturity. The scores from each section are added to correspond to a specific gestational age in weeks. TABLE 18.2 NEWBORN VITAL SIGNS

The physical maturity section of the examination is done during the first 2 hours after birth. The physical maturity assessment section of the Ballard examination evaluates physical characteristics that appear different at different stages depending on a newborn’s gestational maturity. Newborns who are physically mature have higher scores than those who are not. The areas assessed on the physical maturity examination include: • Skin texture—typically ranges from sticky and transparent to smooth, with varying degrees of peeling and cracking, to parchment-like or leathery with significant cracking and wrinkling • Lanugo—soft downy hair on the newborn’s body, which is absent in preterm newborns, appears with maturity, and then disappears again with postmaturity • Plantar creases—creases on the soles of the feet, which range from absent to

covering the entire foot, depending on maturity (the greater the number of creases, the greater the newborn’s maturity) • Breast tissue—the thickness and size of breast tissue and areola (the darkened ring around each nipple), which range from being imperceptible to full and budding • Eyes and ears—eyelids can be fused or open and ear cartilage and stiffness determine the degree of maturity (the greater the amount of ear cartilage with stiffness, the greater the newborn’s maturity) • Genitals—in males, evidence of testicular descent and appearance of scrotum (which can range from smooth to covered with rugae) determine maturity; in females, appearance and size of clitoris and labia determine maturity (a prominent clitoris with flat labia suggests prematurity, whereas a clitoris covered by labia suggests greater maturity) The neuromuscular maturity section typically is completed within 24 hours after birth. Six activities or maneuvers that the newborn performs with various body parts are evaluated to determine the newborn’s degree of maturity: 1. Posture—How does the newborn hold his or her extremities in relation to the trunk? The greater the degree of flexion, the greater the maturity. For example, extension of arms and legs is scored as 0 points and full flexion of arms and legs is scored as 4 points.

FIGURE 18.3 Gestational age assessment tool. The New Ballard Score (2014). Adapted from http://www.ballardscore.com

2. Square window—How far can the newborn’s hands be flexed toward the wrist? The angle is measured and scored from more than 90 degrees to 0 degrees to determine the maturity rating. As the angle decreases, the newborn’s maturity increases. For example, an angle of more than 90 degrees is scored as –1 point and an angle of 0 degrees is scored as 4 points.

3. Arm recoil—How far do the newborn’s arms “spring back” to a flexed position? This measure evaluates the degree of arm flexion and the strength of recoil. The reaction of the arm is then scored from 0 to 4 points based on the degree of flexion as the arms are returned to their normal flexed position. The higher the points assigned, the greater the neuromuscular maturity (for example, recoil less than a 90-degree angle is scored as 4 points). 4. Popliteal angle—How far will the newborn’s knees extend? The angle created when the knee is extended is measured. An angle of less than 90 degrees indicates greater maturity. For example, an angle of 180 degrees is scored as – 1 point and an angle of less than 90 degrees is scored as 5 points. 5. Scarf sign—How far can the elbows be moved across the newborn’s chest? An elbow that does not reach midline indicates greater maturity. For example, if the elbow reaches or nears the level of the opposite shoulder, this is scored as –1 point; if the elbow does not cross the proximate axillary line, it is scored as 4 points. 6. Heel to ear—How close can the newborn’s feet be moved to the ears? This maneuver assesses hip flexibility: the lesser the flexibility, the greater the newborn’s maturity. The heel-to-ear assessment is scored in the same manner as the scarf sign. After the scoring is completed, the 12 scores are totaled and then compared with standardized values to determine the appropriate gestational age in weeks. Scores range from very low in preterm newborns to very high for mature and postmature newborns. Typically newborns are also classified according to their gestational age as: • Preterm or premature—born prior to 37 completed weeks’ gestation, regardless of birth weight • Term—born between 38 and 42 weeks’ gestation • Post-term or postdates—born after completion of week 42 of gestation • Postmature—born after 42 weeks and demonstrating signs of placental aging Using the information about gestational age and then considering birth weight, newborns can also be classified as follows: • Small for gestational age (SGA) —weight less than the 10th percentile on standard growth charts (usually >5.5 lb)

• Appropriate for gestational age (AGA) —weight between 10th and 90th percentiles • Large for gestational age (LGA) —weight more than the 90th percentile on standard growth charts (usually >9 lb) Chapter 23 describes these variations in birth weight and gestational age in greater detail.

Take Note! Gestational age assessment is important because it allows the nurse to plot growth parameters and to anticipate problems related to prematurity, postmaturity, and growth abnormalities.

Nursing Interventions During the immediate newborn period, care focuses on helping the newborn to make the transition to extrauterine life. The nursing interventions include maintaining airway patency, ensuring proper identification, administering prescribed medications, and maintaining thermoregulation.

Maintaining Airway Patency Immediately after birth, a newborn is suctioned to remove fluids and mucus from the mouth and nose (Fig. 18.4). Typically, the newborn’s mouth is suctioned first with a bulb syringe to remove debris and then the nose is suctioned. Suctioning in this manner helps prevent aspiration of fluid into the lungs by an unexpected gasp. Recent studies, along with recommendations from leading maternal health experts and the WHO, support using a towel to wipe secretions from the mouth and nose of newborns for stable newborns. Routine suctioning of the mouth and airways is not required. Despite evidence showing that the use of routine suctioning shows no benefit and may produce harm, the practice remains commonplace (Bond, 2015; Saugstad, 2015). When suctioning a newborn with a bulb syringe, compress the bulb before placing it into the oral or nasal cavity. Release bulb compression slowly, making sure the tip is placed away from the mucous membranes to draw up the excess secretions. Remove the bulb syringe from the mouth or nose, and then, while holding the bulb syringe tip over an emesis basin lined with paper towel or tissue, compress the bulb to expel the secretions. Repeat the procedure several times until all secretions are removed or use a towel to wipe away secretions per hospital policy.

FIGURE 18.4 A newborn is suctioned by means of a bulb syringe to remove mucus from the mouth and nose. The head-down-and-to-the-side position facilitates drainage. Care is given with the infant under a radiant heat source. (Copyright Caroline Brown, RNC, MS, DEd.)

Take Note! Always keep a bulb syringe near the newborn in case he or she develops sudden choking or a blockage in the nose. It may be lifesaving.

Ensuring Proper Identification Infant abduction continues to be a threat in hospitals and health care organizations across the country. The abduction by nonfamily members of newborns from health care facilities has clearly become a subject of concern for parents, maternal-child care nurses, health care security and risk management administrators, law enforcement officials, and the National Center for Missing & Exploited Children (NCMEC). Staff identification (ID) badges, training, video surveillance, access control and tagging systems can help prevent a newborn from being abducted from the hospital. Proactive security measures must become everyone’s responsibility to ensure the safety of all newborns and their families in all hospital settings. Before the newborn and family leave the birthing area, be sure that agency policy about identification has been followed. Typically, the mother, the newborn, and the father or any significant other or support person of the mother’s choosing receive ID bracelets. The newborn commonly receives two ID bracelets, one on a wrist and one on an ankle. The mother receives a

matching one, usually on her wrist. The ID bands usually state name, gender, date and time of birth, and identification number. The same identification number is on the bracelets of all family members. These ID bracelets are provided for the safety of the newborn and must be secured before the mother and newborn leave the birthing area. The ID bracelets are checked by all nurses to validate that the correct newborn is brought to the right mother if they are separated for any period of time (Fig. 18.5). They also serve as the official newborn identification and should be checked before initiating any procedure on that newborn and on discharge from the unit (NCMEC, 2015). Taking the newborn’s picture within 2 hours after birth with a color camera or color video/digital image also helps prevent mix-ups and abduction. Many facilities use electronic devices that sound an alarm if a newborn is taken beyond a certain point on the unit or removed from the area.

FIGURE 18.5 The nurse checks the newborn’s identification band against the mother’s.

Newborns’ footprints may also be taken, using a form that includes the mother’s fingerprint, name, date, and time of the birth. Some states require footprints of the newborn, although many studies point out that birthing room staff does not take consistently legible footprints suitable for identification purposes (Goyal, Nagar, & Kumar, 2014). Many states have stopped requiring newborn footprints, and thus other means of identification are needed, such as collecting cord blood at the time of birth for DNA testing; facial biometric recognition, and live scans to capture digital forensic-quality prints that are suitable for identification purposes (Otsuka, 2014). Prevention of infant abductions has been successful through a combination of

increased security measures in hospitals, including video cameras and alarm devices, and education of staff and parents about precautions to take while in the hospital. It is critical not to allow anyone without identification to take an infant for any reason and to keep the infant within the sight of the parent or nursery staff at all times. These measures should be largely invisible and create a sense of security rather than increasing parental fears about abduction. Although infant abduction rates are rare, the safety and security of mothers and infants should remain a high priority for nurses. By being aware of physical security of maternity units, educating expectant parents on the methods used by potential abductors, and working with community resources, these tragic incidents can be prevented.

Administering Prescribed Medications During the immediate newborn period, two medications are commonly ordered: vitamin K and eye prophylaxis with either erythromycin or tetracycline ophthalmic ointment (Drug Guide 18.1). VITAMIN K Prophylactic treatment of newborns with intramuscular vitamin K has been the standard of care for decades in the United States. Vitamin K, a fat-soluble vitamin, promotes blood clotting by increasing the synthesis of prothrombin by the liver. A deficiency of this vitamin delays clotting and might lead to hemorrhage. Newborns are at risk for vitamin K deficiency and subsequent bleeding unless supplemented at birth. Vitamin K deficiency is an acquired coagulopathy in newborn infants because of an accumulation of inactive vitamin K coagulation factors, which leads to an increased bleeding tendency. Supplementation of vitamin K at birth has been recommended in the United States since 1961 and successfully reduces the risk of bleeding in newborns (Bellini, 2015).

DRUG GUIDE 18.1 DRUGS FOR THE NEWBORN

Generally, the bacteria of the intestine produce vitamin K in adequate quantities. However, the newborn’s bowel is sterile, so vitamin K is not produced in the intestine until after microorganisms have been introduced, such as with the first feeding. Usually, it takes about a week for the newborn to produce enough vitamin K to prevent vitamin K deficiency bleeding. An oral vitamin K preparation is also being given to newborns outside the United States, but at least three doses are needed over a 1-month period (Abrams & Savelli, 2014). The efficacy of vitamin K in preventing early vitamin K deficiency bleeding is firmly established and has been the standard of care since the AAP recommended it in the early 1960s. The AAP (2015c) recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg (Fig. 18.6). The AAP also suggests that additional research is needed to validate the efficacy and safety of oral forms of vitamin K, which have been used in many parts of the world, but currently are not recommended in the United States. EYE PROPHYLAXIS All newborns in the United States, whether delivered vaginally or by cesarean

birth, must receive an installation of a prophylactic agent in their eyes within an hour or two of birth. This is mandated in all 50 states to prevent ophthalmia neonatorum, which can cause neonatal blindness (Centers for Disease Control and Prevent [CDC], 2015a). Ophthalmia neonatorum is a hyperacute purulent conjunctivitis occurring during the first 10 days of life. It is usually contracted during birth when the baby comes in contact with vaginal discharge of the mother infected with gonorrhea and chlamydia (CDC, 2015a). Most often both eyelids become swollen and red with purulent discharge.

FIGURE 18.6 The nurse administers vitamin K IM to the newborn.

FIGURE 18.7 The nurse administers eye prophylaxis.

Prophylactic agents that are currently recommended (and in most states legally required) include erythromycin 0.5% ophthalmic ointment or tetracycline 1% ophthalmic ointment in a single application. Silver nitrate solution was

formerly used but has little efficacy in preventing chlamydial eye disease (Moore & MacDonald, 2015). Regardless of which agent is used, instillation should be done as soon as possible after birth (Fig. 18.7). If instillation is delayed to allow visualization and bonding, the nursery staff should make sure the agent is administered when the newborn reaches the nursery for observation and assessment. Inform all parents about the eye treatment, including why it is recommended, what problems may arise if the treatment is not given, and possible adverse effects of the treatment.

Take Note! Ophthalmia neonatorum is a severe form of conjunctivitis caused by chlamydia and/or gonococcal infections that is potentially a blinding condition in newborns.

Maintaining Thermoregulation Newborns have trouble regulating their temperature; especially during the first few hours after birth (see Chapter 17 for a complete discussion). Therefore, maintaining body temperature is crucial. Concept Mastery Alert Use of a Radiant Heater in Preventing Newborn Heat Loss A 1-day-old infant should have adequate thermoregulation to remain out of the radiant heater. The best way to prevent heat loss is to ensure that the infant does not come in contact with cold surfaces.

Assess body temperature frequently during the immediate newborn period. The baby’s temperature should be taken every 30 minutes for the first 2 hours or until the temperature has stabilized, and then every 8 hours until discharge or follow hospital protocols (King et al., 2015). Commonly a thermistor probe (automatic sensor) is attached to the newborn to record body temperature on a

monitoring device. The probe is taped to the newborn’s abdomen, usually in the right upper quadrant, which allows for position changes without having to readjust the probe. The other end of the thermistor probe is inserted into the radiant heat control panel. Temperature parameters are set on an alarm system connected to the heat panel that will sound if the newborn’s temperature falls out of the set range. Check the probe connection periodically to make sure that it remains secure. Remember the potential for heat loss in newborns, and perform all nursing interventions in a way that minimizes heat loss and prevents hypothermia. Axillary temperatures can also be used to assess the newborn’s body temperature. Place a thermometer under the newborn’s axilla and place the arm over the chest to keep the thermometer in place and provide comfort to the newborn. Nursing interventions to help maintain body temperature include: • Dry the newborn immediately after birth to prevent heat loss through evaporation. • Wrap the baby in warmed blankets to reduce heat loss via convection. • Skin-to-skin contact with mother as soon as stabilized. • Use a warmed cover on the scale to weigh the unclothed newborn. • Warm stethoscopes and hands before examining the baby or providing care. • Avoid placing newborns in drafts or near air vents to prevent heat loss through convection. • Delay the initial bath until the baby’s temperature has stabilized to prevent heat loss through evaporation. • Avoid placing cribs near cold outer walls to prevent heat loss through radiation. • Put a cap on the newborn’s head after it is thoroughly dried after birth. • Place the newborn under a temperature-controlled radiant warmer (Fig. 18.8).

NURSING MANAGEMENT DURING THE EARLY NEWBORN PERIOD The early newborn period is a time of great adjustment for both the mother and the newborn; both of them are adapting to many physiologic and psychological changes. In the past, mothers and newborns remained in the health care facility while these dramatic changes were taking place, with nurses and doctors readily available. However, today shorter hospital stays are the norm, and new mothers can easily be overwhelmed by having to go through all of these changes in such a short time: the woman gives birth, experiences marked physiologic and psychological changes, and must adapt to her newborn and learn the skills needed to care for herself and the baby, all within 24 to 48 hours.

FIGURE 18.8 Maintaining thermoregulation. A. Radiant warmer. B. Isolette.

The nurse’s role is to assist the mother and her newborn through this dramatic transition period. The newborn needs continued health assessment, and the mother needs to be taught to care for the new baby. At discharge, the new mother may panic and feel insecure about her role as a primary caretaker. Nurses play a major role in promoting the newborn’s transition by providing ongoing

assessment and care and in promoting the woman’s confidence by serving as a role model and teaching about proper newborn care.

Assessment The newborn requires ongoing assessment after leaving the birthing area to ensure that his or her transition to extrauterine life is progressing without problems. The nurse uses the data gathered during the initial assessment as a baseline for comparison.

Perinatal History Pertinent maternal and fetal data are vital to formulate a plan of care for the mother and her newborn. Historical information is obtained from the medical record and from interviewing the mother. Review the maternal history because it provides pertinent information, such as the presence of certain risk factors that could affect the newborn. Keep in mind that a comprehensive maternal history may not be available, especially if the mother has had limited or no prenatal care. Historical information usually includes the following: • Mother’s name, medical record number, blood type, serology result, rubella and hepatitis status, and history of substance abuse • Other maternal tests that are relevant to the newborn and care, such as human immunodeficiency virus (HIV) and group B streptococcus status • Intrapartum maternal antibiotic therapy (type, dose, and duration) • Maternal illness that can affect the pregnancy, evidence of chorioamnionitis, maternal use of medications such as steroids • Prenatal care, including timing of first visit and subsequent visits • Risk for blood group incompatibility, including Rh status and blood type • Fetal distress or any nonreassuring fetal heart rate patterns during labor • Known inherited conditions such as sickle cell anemia and phenylketonuria (PKU) • Birth weights of previous live-born children, along with identification of any newborn problems • Social history, including tobacco, alcohol, and recreational drug use • History of depression or domestic violence • Cultural factors, including primary language and educational level

• Pregnancy complications associated with abnormal fetal growth, fetal anomalies, or abnormal results from tests of fetal well-being • Information on the progress of labor, birth, labor complications, duration of ruptured membranes, and presence of meconium in the amniotic fluid • Medications given during labor, at birth, and immediately after birth • Time and method of delivery, including presentation and the use of forceps or a vacuum extractor • Status of the newborn at birth, including Apgar scores at 1 and 5 minutes, the need for suctioning, weight, gestational age, vital signs, and umbilical cord status • Medications administered to the newborn • Postbirth maternal information, including placental findings, positive cultures, and presence of fever

Newborn Physical Examination The initial newborn physical examination, which may demonstrate subtle differences related to the newborn’s age, is carried out within the first 24 hours after birth. For example, a newborn who is 30 minutes old has not yet completed the normal transition from intrauterine to extrauterine life, and thus variability may exist in vital signs and in respiratory, neurologic, gastrointestinal, skin, and cardiovascular systems. Therefore, a comprehensive examination should be delayed until after the newborn has completed the transition. The physical examination should not be initiated if the newborn is crying or appears to be upset. Instead, it is best to postpone the assessment until the newborn is calm. In a quiet newborn, begin the examination with the least invasive and noxious elements of the examination (auscultation of heart and lungs). Then examine the areas most likely to irritate the newborn (e.g., examining the hips and eliciting the Moro reflex). A general visual assessment provides an enormous amount of information about the well-being of a newborn. Initial observation gives an impression of a healthy (stable) versus an ill newborn and a term versus a preterm newborn. A typical physical examination of a newborn includes a general survey of skin color, posture, state of alertness, head size, overall behavioral state, respiratory status, gender, and any obvious congenital anomalies. Check the overall appearance for anything unusual. Then complete the examination in a systematic

fashion. Remember Kelly, who called the home health nurse and said her newborn son “looks like a canary”? What additional information is needed about the baby? What might be causing his yellow color? ANTHROPOMETRIC MEASUREMENTS Shortly after birth, after the gender of the child is revealed, most women and their partners/significant others want to know the vital statistics of their newborn —length and weight—to report to their family and friends. Additional measurements, including head and chest circumference, are also taken and recorded. Abdominal measurements are not routinely obtained unless there is a suspicion of pathology that causes abdominal distention. The newborn’s progress from that point onward will be validated based on these early measurements. These measurements will be compared with future serial measurements to determine growth patterns, which are plotted on growth charts to evaluate normalcy. Therefore, accuracy is paramount. Length. The average length of most newborns is 50 cm (20 in), but it can range from 44 to 55 cm (17 to 22 in). Measure length with the unclothed newborn lying on a warmed blanket placed on a flat surface with the knees held in an extended position. Then run a tape measure down the length of the newborn— from the head to the soles of the feet—and record this measurement in the newborn’s record (see Fig. 18.1). Weight. At birth the average newborn weighs 3,400 g (7.5 lb), but normal birth weights can range from 2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 14 oz). Newborns are weighed immediately after birth and then daily. Newborns usually lose up to 6% of their birth weight within the first few days of life, but regain it in approximately 10 days. Newborns are weighed on admission to the nursery or are taken to a digital scale to be weighed and returned to the mother’s room. First, balance the scale if it is not balanced. Place a warmed protective cloth or paper as a barrier on the scale to prevent heat loss by conduction; recalibrate the scale to zero after applying the barrier. Next, place the unclothed newborn in the center of the scale. Keep a hand above the newborn for safety (see Fig. 18.2).

Weight is affected by racial origin, genetics, maternal age, size of the parents, maternal nutrition, maternal weight prenatally, and placental perfusion (Tawia & McGuire, 2014). Weight should be correlated with gestational age. A newborn who weighs more than normal might be LGA or an infant of a diabetic mother; a newborn who weighs less than normal might be SGA, preterm, or have a genetic syndrome. It is important to identify the cause for the deviation in size and to monitor the newborn for complications common to that etiology. Head Circumference. The average newborn head circumference is 32 to 38 cm (13 to 15 in). Measure the circumference at the head’s widest diameter (the occipitofrontal circumference). Wrap a flexible or paper measuring tape snugly around the newborn’s head and record the measurement (Fig. 18.9A).

Take Note! Head circumference may need to be remeasured at a later time if the shape of the head is altered from birth.

FIGURE 18.9 A. Measuring head circumference. B. Measuring chest circumference.

The head circumference should be approximately one fourth of the newborn’s length or about half the infant’s body length plus 10 cm. Expected head circumference for a term infant is between 32 and 37 cm (12.5 to 14.5 in) (Nagtalon-Ramos, 2014). A small head might indicate microcephaly caused by rubella, toxoplasmosis, or SGA status; an enlarged head might indicate hydrocephalus or increased intracranial pressure. Both need to be documented and reported for further investigation. Chest Circumference. The average chest circumference is 30 to 36 cm (12 to 14 in). It is generally equal to or about 2 to 3 cm less than the head circumference (Weber & Kelley, 2014). Place a flexible or paper tape measure around the unclothed newborn’s chest just below the nipple line without pulling it taut (see Fig. 18.9B).

Take Note! The head and chest circumferences are usually equal by about 1 year of age. VITAL SIGNS In the newborn, temperature, pulse, and respirations are monitored frequently and compared with baseline data obtained immediately after birth. Generally, vital signs (excluding blood pressure) are taken: • On admission to the nursery or in the labor and birth room after the woman/parents are allowed to hold and bond with the newborn • Once every 30 minutes until the newborn has been stable for 2 hours • Then once every 4 to 8 hours until discharge (Davidson, 2014) Blood pressure is not routinely assessed in a normal newborn unless the baby’s clinical condition warrants it. This schedule can change depending on the baby’s health status. Obtain a newborn’s temperature by placing an electronic temperature probe in the midaxillary area or by monitoring the electronic thermistor probe that has been taped to the abdominal skin (applied when the newborn was placed under a radiant heat source). Monitor the newborn’s temperature frequently per hospital protocol for changes until it stabilizes. If the temperature is higher, adjust the environment, such as removing some clothing or blankets. If the temperature is lower, check the radiant warmer setting or add a warmed blanket. Report any abnormalities to the primary health care provider if simple adjustments to the environment do not change the baby’s temperature. Obtain an apical pulse by placing the stethoscope over the fourth intercostal space on the chest. Listen for a full minute, noting rate, rhythm, and abnormal sounds such as murmurs. In the typical newborn, the heart rate is 120 to 160 bpm, with wide fluctuations with activity and sleep. Sinus arrhythmia is a normal finding. Murmurs detected during the newborn period do not necessarily indicate congenital heart disease, but they need to be evaluated further if they persist. Also palpate the apical, femoral, and brachial pulses for presence and equality (Fig. 18.10). Report any abnormalities to the primary health care provider for evaluation. Assess respirations by observing the rise and fall of the chest for 1 full minute.

Respirations should be symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The newborn’s respirations are predominantly diaphragmatic, but they are synchronous with abdominal movements. Also auscultate breath sounds. Note any abnormalities, such as tachypnea, bradypnea, grunting, gasping, periods of apnea lasting longer than 20 seconds, asymmetry or decreased chest expansion, abnormal breath sounds (rhonchi and crackles), or sternal retractions. Some variations might exist early after birth, but if the abnormal pattern persists, notify the primary health care provider.

FIGURE 18.10 Assessing the newborn’s vital signs. A. Assessing the apical pulse. B. Palpating the femoral pulse. C. Palpating the brachial pulse.

SKIN The newborn’s skin is similar in structure to the adult’s, but many of the functions are not fully developed. Observe the overall appearance of the skin, including color, texture, turgor, and integrity. The newborn’s skin should be smooth and flexible, and the color should be consistent with genetic background. Skin Condition and Color. Check skin turgor by pinching a small area of skin over the chest or abdomen and note how quickly it returns to its original position. In a well-hydrated newborn, the skin should return to its normal position immediately. Skin that remains “tented” after being pinched may indicate dehydration. A small amount of lanugo (fine downy hair) may be

observed over the shoulders and on the sides of the face and upper back. There may be some cracking and peeling of the skin. The skin should be warm to the touch and intact. The newborn’s skin often appears blotchy or mottled, especially in the extremities. Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness is called acrocyanosis (Fig. 18.11). It may be seen in newborns during the first few weeks of life in response to exposure to cold. Acrocyanosis is normal and intermittent. Any change in color of the newborn skin needs further investigation. Newborn Skin Variations. While assessing the skin, make note of any rashes, ecchymoses or petechiae, nevi, or dark pigmentation. Skin lesions can be congenital or transient; they may be a result of infection or may result from the mode of birth. If any of them are present, observe the anatomic location, arrangement, type, and color. Bruising may result from the use of devices such as a vacuum extractor during delivery. Petechiae may be the result of pressure on the skin during the birth process. Forceps marks may be observed over the cheeks and ears. A small puncture mark may be seen if internal fetal scalp electrode monitoring was used during labor. Common skin variations include vernix caseosa, stork bites or salmon patches, milia, Mongolian spots, erythema toxicum, harlequin sign, nevus flammeus, and nevus vasculosus (Fig. 18.12).

FIGURE 18.11 Acrocyanosis. This commonly appears on the feet and hands of babies shortly after birth. This infant is a 32-week newborn. (From Fletcher M. [1998]. Physical diagnosis in neonatology. Philadelphia, PA: Lippincott-Raven Publishers.)

FIGURE 18.12 Common skin variations. A. Stork bite. B. Milia. C. Mongolian spots. D. Erythema toxicum. E. Nevus flammeus (port-wine stain). F. Strawberry hemangioma.

Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus’s oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. It does not need to be removed because it will be absorbed into the skin.

Stork bites or salmon patches are superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip (see Fig. 18.12A). The name comes from the marks on the back of the neck where, as myth goes, a stork may have picked up the baby. They are caused by a concentration of immature blood vessels and are most visible when the newborn is crying. They are considered a normal variant, and most fade and disappear completely within the first year. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn’s nose. They may also appear on the chin and forehead (see Fig. 18.12B). They form from oil glands and disappear on their own within 2 to 4 weeks. When they occur in a newborn’s mouth and gums, they are termed Epstein’s pearls. They occur in approximately 80% of newborns. As most lesions break spontaneously within the first few weeks of life, no therapy is indicated (El-Radhi, 2015). Mongolian spots are benign blue or purple splotches that appear solitary on the lower back and buttocks of newborns, but may occur as multiple over the legs and shoulders (see Fig. 18.12C). They tend to occur in African American, Asian, Hispanic, and Indian newborns but can occur in dark-skinned newborns of all races. The spots are caused by a concentration of pigmented cells and usually disappear spontaneously within the first 4 years of life. They should not be confused with bruises caused by trauma (Silverberg, 2015). Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. It is often mistaken for staphylococcal pustules. The rash is common on the face, chest, and back (see Fig. 18.12D). One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn’s eosinophils reacting to the environment as the immune system matures. Histologically, erythema toxicum shows an abundance of eosinophils. Although it has been recognized and described for centuries, its etiology and pathogenesis remain unclear (Gloster, Gebauer, & Mistur, 2016a). It does not require any treatment and disappears in a few days. Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. It results from immature autoregulation of blood flow and is commonly seen in low-birth-weight

newborns when there is a positional change (Lomax, 2015). It is transient, lasting as long as 20 minutes, and no intervention is needed. Nevus flammeus, also called a port-wine stain, commonly appears on the newborn’s face or other body areas (see Fig. 18.12E). It is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple red. This skin lesion is made up of mature capillaries that are congested and dilated. It ranges in size from a few millimeters to large, occasionally involving as much as half the body surface. Although it does not grow in area or size, it is permanent and will not fade. Although they may occur anywhere on the body, the majority are located in the head and neck areas. Port-wine stains may be associated with structural malformations, bony or muscular overgrowth, and certain cancers. Recent studies have noted an association between port-wine birthmarks and childhood cancer, so newborns with these lesions should be monitored with periodic eye examinations, neurologic imaging, and extremity measurements. Lasers and intense pulsed light have been used to remove larger lesions with some success. The optimal timing of treatment is before 1 year of age (Giese & Richter, 2015). Nevus vasculosus, also called a strawberry mark or strawberry hemangioma, is a benign capillary hemangioma in the dermal and subdermal layers. It is raised, rough, dark red, and sharply demarcated (see Fig. 18.12F). It is commonly found in the head region within a few weeks after birth and can increase in size or number. They are commonly found in about 10% of children. This type of hemangioma may be very subtle or even absent in the first few weeks of life, but they proliferate in the first few months of life. Commonly seen in premature infants weighing less than 1,500 g (El-Radhi, 2015), these hemangiomas tend to resolve by age 3 without any treatment. The most important aspects of nursing management related to newborn skin variations include: adequate recognition of the lesions and knowledge of their natural history so that accurate information can be offered to the parents/significant other or partner. The majority of the skin lesions do not require any therapeutic intervention, but referral is necessary if there is: visual, airway or ear-canal obstruction, extensive growth, severe facial disfigurement, recurrent bleeding, infection, or ulceration, or excessive concern by the parents. HEAD Head size varies with age, gender, and ethnicity and has a general correlation with body size. Inspect a newborn’s head from all angles. The head should

appear symmetric and round. As many as 90% of the congenital malformations present at birth are visible on the head and neck, so careful assessment is very important (Pfister & Ramel, 2014). The newborn has two fontanels at the juncture of the cranial bones. The anterior fontanel is diamond shaped and closes by 18 to 24 months. Typically it measures 4 to 6 cm at the largest diameter (bone to bone). The posterior one is triangular, smaller than the anterior fontanel (usually fingertip size or 0.5 to 1 cm), and closes by 6 to 12 weeks. Palpate both fontanels, which should be soft, flat, and open. Then palpate the skull. It should feel somewhat smooth and fused, except at the area of the fontanels, over molding areas, and sutures. Also assess the size of the head and the anterior and posterior fontanels, and compare them with appropriate standards. Variations in Head Size and Appearance. During inspection and palpation, be alert for common variations that may cause asymmetry. These include molding, caput succedaneum, and cephalhematoma. Molding is the elongated shaping of the fetal head to accommodate passage through the birth canal (Fig. 18.13). It occurs with a vaginal birth from a vertex position in which elongation of the fetal head occurs with prominence of the occiput and overriding sagittal suture line. It typically resolves within a week after birth without intervention.

FIGURE 18.13 Molding in a newborn’s head.

Caput succedaneum describes localized edema on the scalp that occurs from the pressure of the birth process. It is commonly observed after prolonged labor. Clinically, it appears as a poorly demarcated soft tissue swelling that crosses suture lines. Pitting edema and overlying petechiae and ecchymosis are noted (Fig. 18.14A). The swelling will gradually dissipate in about 3 days without any treatment. Newborns who were delivered via vacuum extraction usually have a caput in the area where the cup was used. Cephalhematomais a localized subperiosteal collection of blood of the skull which is always confined by one cranial bone. This condition is due to pressure on the head and disruption of the vessels during birth. It occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum extraction. The clinical features include a well-demarcated, often fluctuant swelling with no overlying skin discoloration. The swelling does not cross suture lines and is firmer to the touch than an edematous area (see Fig. 18.14B). Aspiration is not required for resolution and is likely to increase the risk of infection. Hyperbilirubinemia occurs following the breakdown of the red blood cells within the hematoma. This type of hyperbilirubinemia occurs later than

classic physiologic hyperbilirubinemia. Cephalhematoma usually appears on the second or third day after birth and disappears within weeks or months. Large cephalhematomas can lead to increased bilirubin levels and subsequent jaundice (Lomax, 2015). Common Abnormalities in Head or Fontanel Size. Common abnormalities in head or fontanel size that may indicate a problem include: • Microcephaly—a head circumference more than 2 standard deviations below average or less than 10% of normal parameters for gestational age, caused by failure of brain development. There is a reduced production of neurons leading to a reduction of brain volume and as a consequence of that a reduced skull size. Microcephaly is common, affecting more than 25,000 infants in the United States each year. Children with severe microcephaly, defined as more than 3 standard deviations below the mean for age and sex, are more likely to have imaging abnormalities and more severe developmental impairments than those with milder microcephaly. About 40% of children with microcephaly also have epilepsy, 20% have cerebral palsy, 50% have intellectual disability, and 20% to 50% have ophthalmologic and hearing disorders (Boom, 2015a). It can be familial, with autosomal dominant or recessive inheritance, and it may be associated with infections (cytomegalovirus), rubella, toxoplasmosis, and syndromes such as trisomy 13, 18, or 21 and fetal alcohol syndrome. Genetic counseling and clinical management through carrier detection/prenatal diagnosis in families can help reduce the incidence of these disorders (Alcantara & O’Driscoll, 2014). • Macrocephaly—a head circumference more than 90% of normal, typically related to hydrocephalus (Boom, 2015b). It is often familial (with autosomal dominant inheritance) and can be either an isolated anomaly or a manifestation of other anomalies, including hydrocephalus and skeletal disorders (achondroplasia). • Large fontanels—more than 6 cm in the anterior diameter bone to bone or more than a 1-cm diameter in the posterior fontanel; possibly associated with malnutrition, hydrocephaly, congenital hypothyroidism, trisomies 13, 18, and 21, and various bone disorders such as osteogenesis imperfecta. • Small or closed fontanels—smaller-than-normal anterior and posterior diameters or fontanels that are closed at birth. Craniosynostosis and abnormal brain development are associated with a small fontanel or early fontanel

closure associated with microcephaly (Sheth, Ranalli, & Aldana, 2014). FACE Observe the newborn’s face for fullness and symmetry. The face should have full cheeks and should be symmetric when the baby is resting and crying. If forceps were used during birth, the newborn may have bruising and reddened areas over both cheeks and parietal bones secondary to the pressure of the forceps blades. Reassure the parents that this resolves without treatment, and point out improvement each day.

FIGURE 18.14 A1 and A2. Caput succedaneum involves the collection of serous fluid and often crosses the suture line. (A2.. From Chung, Visual diagnosis and treatment in pediatrics (2nd ed.). Philadelphia: LWW.) B1 and B2. Cephalhematoma involves the collection of blood and does not cross the suture line. (Photos, except for (A2), from O’Doherty, N. (1979). Atlas of the newborn. Philadelphia: J B Lippincott, 1979:136, and 1979:117, 143, with permission.)

Problems with the face can also involve facial nerve paralysis caused by trauma from the use of forceps. Paralysis is usually apparent on the first or second day of life. Typically, the newborn will demonstrate asymmetry of the face with an inability to close the eye and move the lips on the affected side. Newborns with facial nerve paralysis have difficulty making a seal around the nipple, and consequently milk or formula drools from the paralyzed side of the mouth. Most facial nerve palsies resolve spontaneously within days, although full recovery may require weeks to months. Attempt to determine the cause from the newborn’s history. Nose. Inspect the nose for size, symmetry, position, and lesions. The newborn’s nose is small and narrow. The nose should have a midline placement, patent nares, and an intact septum. The nostrils should be of equal size and should be patent. A slight mucous discharge may be present, but there should be no actual drainage. The newborn is a preferential nose breather and will use sneezing to clear the nose if needed. The newborn can smell after the nasal passages are cleared of amniotic fluid and mucus (Clark-Gambelunghe & Clark, 2015). Mouth. Inspect the newborn’s mouth, lips, and interior structures. The lips should be intact with symmetric movement and positioned in the midline; there should not be any lesions. Inspect the lips for pink color, moisture, and cracking. The lips should encircle the examiner’s finger to form a vacuum. Variations involving the lip might include cleft upper lip (separation extending up to the nose) or thin upper lip associated with fetal alcohol syndrome. Assess the inside of the mouth for alignment of the mandible, intact soft and hard palate, sucking pads inside the cheeks, a midline uvula, a free-moving tongue, and working gag, swallow, and sucking reflexes. The mucous membranes lining the oral cavity should be pink and moist, with minimal saliva present. Normal variations might include Epstein’s pearls (small, white epidermal cysts on the gums and hard palate that disappear in weeks), erupted natal teeth that may need to be removed to prevent aspiration (Fig. 18.15), and thrush (white plaque inside the mouth caused by exposure to Candida albicans during birth), which cannot be wiped away with a cotton-tipped applicator. Eyes. Inspect the external eye structures, including the eyelids, lashes, conjunctiva, sclera, iris, and pupils, for position, color, size, and movement. There may be marked edema of the eyelids and subconjunctival hemorrhages

due to pressure during birth. The eyes should be clear and symmetrically placed. Test the blink reflex by bringing an object close to the eye; the newborn should respond quickly by blinking. Also test the newborn’s pupillary reflex: pupils should be equal, round, and reactive to light bilaterally. Assess the newborn’s gaze: he or she should be able to track objects to the midline. Movement may be uncoordinated during the first few weeks of life. Many newborns have transient strabismus (deviation or wandering of eyes independently) and searching nystagmus (involuntary repetitive eye movement), which is caused by immature muscular control. These are normal for the first 3 to 6 months of age.

FIGURE 18.15 A natal tooth in a 16-day-old neonate. Natal teeth can be present at birth and are usually considered benign. No treatment is needed if they don’t interfere with feeding.

Examine the internal eye structures. A red reflex (luminous red appearance seen on the retina) should be seen bilaterally on retinoscopy. The red reflex normally shows no dullness or irregularities. Chemical conjunctivitis commonly occurs within 24 hours of instillation of eye prophylaxis after birth. There is lid edema with sterile discharge from both eyes. Usually it resolves within 48 hours without treatment. Ears. Inspect the ears for size, shape, skin condition, placement, amount of cartilage, and patency of the auditory canal. The ears should be soft and pliable and should recoil quickly and easily when folded and released. Ears should be aligned with the outer canthi of the eyes. Low-set ears and abnormally shaped ears are characteristic of many syndromes and genetic abnormalities, such as trisomy 13 or 18, and internal organ abnormalities involving the renal system. Findings of sinuses or preauricular skin tags should prompt further evaluation

for possible renal abnormalities since both systems develop at the same time. An otoscopic examination is not typically done because the newborn’s ear canals are filled with amniotic fluid and vernix caseosa, which would make visualization of the tympanic membrane difficult. Newborn hearing screening is required by law in most states (discussed later in the chapter). Hearing loss is the most common birth defect in the United States: One in 1,000 newborns are profoundly deaf and 3 in 1,000 have some degree of hearing impairment (March of Dimes, 2015a). Delays in identification and intervention may affect the child’s cognitive, verbal, behavioral, and emotional development. Screening at birth has reduced the age at which newborns with hearing loss are identified and has improved early intervention rates dramatically. Available treatments include cochlear implantation, hearing augmentation, and follow-up by an audiologist, otolaryngologist, pediatrician, geneticist, and deaf education specialist (Nikolopoulos, 2015). Prior to universal newborn screening, children were usually older than 2 years before significant congenital hearing loss was detected; by this time it had already affected their speech and language skills (CDC, 2015b). Causes of hearing loss can be conductive, sensorineural, or central. Risk factors for congenital hearing loss include cytomegalovirus infection and preterm birth necessitating a stay in the neonatal intensive care unit. To assess for hearing ability generally, observe the newborn’s response to noises and conversations. The newborn typically turns toward these noises and startles with loud ones. NECK Inspect the newborn’s neck for movement and ability to support the head. The newborn’s neck will appear almost nonexistent because it is so short. Creases are usually noted. The neck should move freely in all directions and should be capable of holding the head in a midline position. The newborn should have enough head control to be able to hold it up briefly without support. Report any deviations such as restricted neck movement or absence of head control. Also inspect the clavicles (collarbone), which should be straight and intact. The clavicles are the bones mostly commonly broken in infants, especially large ones experiencing difficult births, in operative vaginal births, abnormal fetal positions, and in maternal obesity. In most cases, the fractured clavicle is asymptomatic, but edema, crepitus, and decreased or absent movement and pain

or tenderness on movement of the arm on the affected side may be noted. Major risk factors for clavicle fractures are typically vacuum births and large newborn birth weights (Ahn et al., 2015). If the newborn with clavicular fracture is in pain, the affected arm should be immobilized, with the arm abducted more than 60 degrees and the elbow flexed more than 90 degrees. In addition to immobilization, treatment involves minimizing pain overall. CHEST Inspect the newborn’s chest for size, shape, and symmetry. The newborn’s chest should be round, symmetric, and 2 to 3 cm smaller than the head circumference. The xiphoid process may be prominent at birth, but it usually becomes less apparent when adipose tissue accumulates. Nipples may be engorged and may secrete a white discharge. This discharge, which occurs in both boys and girls, is a result of exposure to high levels of maternal estrogen while in utero. This enlargement and milky discharge usually dissipates within a few weeks. Some newborns may have extra nipples, called supernumerary nipples. They are typically small, raised, pigmented areas vertical to the main nipple line, 5 to 6 cm below the normal nipple. Supernumerary nipples may be unilateral or bilateral, and they may include an areola, nipple, or both. They tend to be familial and do not contain glandular tissue. Supernumerary nipples are generally thought to be benign. Some studies have suggested an association with renal or urogenital anomalies, whereas other studies have failed to show this association. There is insufficient evidence to recommend imaging studies or removal in the absence of other clinical concerns or physical findings (Gloster, Gebauer, & Mistur, 2016b). Reassure parents that these extra small nipples are harmless. The newborn chest is usually barrel shaped, with equal anteroposterior and lateral diameters, and symmetric. Auscultate the lungs bilaterally for equal breath sounds. Normal breath sounds should be heard, with little difference between inspiration and expiration. Fine crackles can be heard on inspiration soon after birth as a result of amniotic fluid being cleared from the lungs. Diminished breath sounds might indicate atelectasis or pneumonia (Weber & Kelley, 2014). Listen to the heart when the newborn is quiet or sleeping. S1 and S2 heart sounds are accentuated at birth. The point of maximal impulse is a lateral to midclavicular line located at the fourth intercostal space. A displaced point of maximal impulse may indicate tension pneumothorax or cardiomegaly. Murmurs

are common during the first few hours as the foramen ovale is closing. Although cardiac murmurs in the neonatal period do not necessarily indicate heart disease, they should be evaluated if they persist (Fillipps & Bucciarelli, 2015). ABDOMEN Inspect the abdomen for shape and movement. Typically, the newborn’s abdomen is protuberant but not distended. This contour is a result of the immaturity of the abdominal muscles. Abdominal movements are synchronous with respirations because newborns are, at times, abdominal breathers. Auscultate bowel sounds in all four quadrants and then palpate the abdomen for consistency, masses, and tenderness. Perform auscultation and palpation systematically in a clockwise fashion until all four quadrants have been assessed. Palpate gently to feel the liver, the kidneys, and any masses. The liver is normally palpable 1 to 3 cm below the costal margin in the midclavicular line. The kidneys are 1 to 2 cm above and to both sides of the umbilicus. Normal findings would include bowel sounds in all four quadrants and no masses or tenderness on palpation. Absent or hyperactive bowel sounds might indicate an intestinal obstruction. Abdominal distention might indicate ascites, obstruction, infection, masses, or an enlarged abdominal organ. The newborn may also show signs of abdominal tenderness (Springer & Glasser, 2015). Imaging is a mainstay to diagnosis abdominal pathology and should be readily performed in a newborn with abdominal distention to determine the underlying etiology. Inspect the umbilical cord area for the correct amount of blood vessels (two arteries and one vein). The umbilical vein is larger than the two umbilical arteries. Evidence of only a single umbilical artery is associated with renal and gastrointestinal anomalies. Also inspect the umbilical area for signs of bleeding, infection, inflammation, redness, swelling, purulent drainage or bleeding, erythema around the umbilicus, granuloma, or abnormal communication with the intra-abdominal organs. Umbilical infections can occur because of an embryologic remnant or poor hygiene. Traditionally, gram-positive organisms, such as Staphylococcus aureus and Streptococcus pyogenes, were most commonly identified, but gram-negative and polymicrobial infections are seen today. An umbilical cord infection (omphalitis) can spread to adjacent tissue, causing peritonitis, hepatic vein thrombosis and hepatic abscess. Immediate evaluation and referral is needed (Lomax, 2015). GENITALIA

Male. Inspect the penis and scrotum in the male. In the circumcised male newborn, the glans should be smooth, with the meatus centered at the tip of the penis. It will appear reddened until it heals. For the uncircumcised male, the foreskin should cover the glans. Check the position of the urinary meatus: it should be in the midline at the glans’ tip. If it is on the ventral surface of the penis, the condition is termed hypospadias; if it is on the dorsal surface of the penis, it is termed epispadias. In either case, circumcision should be avoided until further evaluation. Inspect the scrotum for size, symmetry, color, presence of rugae, and location of testes. The scrotum usually appears relatively large with well-formed rugae and that should cover the scrotal sac. There should not be bulging, edema, or discoloration (Fig. 18.16A).

FIGURE 18.16 Newborn genitalia. A. Male genitalia. Note the darkened color of the scrotum. B. Female genitalia.

Palpate the scrotum for evidence of the testes, which should be in the scrotal sac. The testes should feel firm and smooth and should be of equal size on both sides of the scrotal sac in the term newborn. Undescended testes (cryptorchidism) might be palpated in the inguinal canal in preterm infants; they can be unilateral or bilateral. If the testes are not palpable within the scrotal sac, further investigation is needed. Female. In the female newborn, inspect the external genitalia. The urethral meatus is located below the clitoris in the midline (Mutter & Prat, 2014). In contrast to the male genitalia, the female genitalia will be engorged: the labia majora and minora may both be edematous. The labia majora is large and covers the labia minora. The clitoris is large and the hymen is thick. These findings are due to the maternal hormones estrogen and progesterone (see Fig. 18.16B). A vaginal discharge composed of mucus mixed with blood may also be present during the first few weeks of life. This discharge, called pseudomenstruation, requires no treatment. Explain this phenomenon to the parents. Variations in female newborns may include a labial bulge, which might indicate an inguinal hernia, ambiguous genitalia, a rectovaginal fistula with feces present in the vagina, and an imperforate hymen. Male and Female. Inspect the anus in both male and female newborns for position and patency. Passage of meconium indicates patency. If meconium is not passed, a lubricated rectal thermometer can be inserted or a digital examination can be performed to determine patency. Abnormal findings would include anal fissures or fistulas and no meconium passed within 24 hours after birth. EXTREMITIES AND BACK Upper Extremities. Inspect the newborn’s upper extremities for appearance and movement. Inspect the hands for shape, number, and position of fingers and presence of palmar creases. The newborn’s arms and hands should be symmetric and should move through the range of motion without hesitation. Observe for spontaneous movement of the extremities. Each hand should have five digits. Note any extra digits (polydactyly) or fusing of two or more digits (syndactyly). Most newborns have three palmar creases on the hand. A single palmar crease, called a simian line, is frequently associated with Down syndrome. A brachial plexus injury can occur during a difficult birth involving shoulder

dystocia. Erb palsy is an injury resulting from damage to the upper plexus, and palsies associated with the lower brachial plexus are termed Klumpke palsies. Factors associated with obstetric brachial plexus paralysis include large birth weight, breech delivery, labor anomalies, operative vaginal birth, and shoulder dystocia. Obstetric brachial plexus paralysis results from excessive lateral traction on the head away from the shoulder. This force on the brachial plexus can cause varying degrees of injury to the nerves. The affected arm hangs limp alongside the body, and the affected shoulder and arm are adducted, extended, and internally rotated with a pronated wrist. The Moro reflex is absent on the affected side in brachial palsy. Complete recovery may take 6 months or longer. Current research studies support endogenous labor forces as the etiology of this injury. Despite training in the management of shoulder dystocia and a rising institutional cesarean section rate, the incidence of brachial plexus injuries has remained unchanged compared with 10 years earlier (Tung & Moore, 2015). Lower Extremities. Assess the lower extremities in the same manner. They should be of equal length, with symmetric skinfolds. Inspect the feet for clubfoot (a turning-inward position), which is secondary to intrauterine positioning. This may be positional or structural. Perform the Ortolani and Barlow maneuvers to identify congenital hip dislocation, commonly termed developmental dysplasia of the hip. Nursing Procedure 18.1 highlights the steps for performing these maneuvers. Table 18.3 summarizes the newborn assessment. NEUROLOGIC STATUS Assess the newborn’s state of alertness, posture, muscle tone, and reflexes. Newborn Alertness, Posture, and Muscle Tone. The newborn should be alert and not persistently lethargic. The normal posture is hips abducted and partially flexed, with knees flexed. Arms are adducted and flexed at the elbow. Fists are often clenched, with fingers covering the thumb.

NURSING PROCEDURE 18.1

Performing Ortolani and Barlow Maneuvers Purpose: To Detect Congenital Developmental Dysplasia of the Hip Ortolani Maneuver 1. Place the newborn in the supine position and flex the hips and knees to 90 degrees at the hip. 2. Grasp the inner aspect of the thighs and abduct the hips (usually to approximately 180 degrees) while applying upward pressure.

3. Listen for any sounds during the maneuver. There should be no “cluck” or “click” heard when the legs are abducted. Such a sound indicates the femoral head hitting the acetabulum as the head reenters the area. This suggests developmental hip dysplasia. Barlow Maneuver 1. With the newborn still lying supine and grasping the inner aspect of the thighs (as just mentioned), adduct the thighs while applying outward and downward pressure to the thighs. 2. Feel for the femoral head slipping out of the acetabulum; also listen for a click.

Inspect the back. The spine should appear straight and flat and should be easily flexed when the baby is held in a prone position. Observe for the presence of a tuft of hair, a pilonidal dimple in the midline, a cyst, or a mass along the spine. These abnormal findings should be documented and reported to the primary health care provider. Adapted from Tamai, J., & McCarthy, J. J. (2015). Developmental dysplasia of the hip. eMedicine. Retrieved from http://emedicine.medscape.com/article/1248135-overview; and Weber, J., & Kelley, J. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

TABLE 18.3 NEWBORN ASSESSMENT SUMMARY

To assess for muscle tone, support the newborn with one hand under the chest. Observe how the neck muscles hold the head. The neck extensors should be able to hold the head in line briefly. There should be only slight head lag when pulling the newborn from a supine position to a sitting one. Newborn Reflexes. Assess the newborn’s reflexes to evaluate neurologic function and development. Absent or abnormal reflexes in a newborn, persistence of a reflex past the age when the reflex is normally lost, or return of an infantile reflex in an older child or adult may indicate neurologic pathology (Table 18.4). Reflexes commonly assessed in the newborn include sucking,

Moro, stepping, tonic neck, rooting, Babinski, palmar grasp and plantar grasp reflexes. Spinal reflexes tested include truncal incurvation (Galant reflex) and anocutaneous reflex (anal wink). The sucking reflex is elicited by gently stimulating the newborn’s lips by touching them. The newborn will typically open the mouth and begin a sucking motion. Placing a gloved finger in the newborn’s mouth will also elicit a sucking motion (Fig. 18.17A). TABLE 18.4 NEWBORN REFLEXES: APPEARANCE AND DISAPPEARANCE

The Moro reflex, also called the embrace reflex, occurs when the neonate is startled. To elicit this reflex, place the newborn on his or her back. Support the upper body weight of the supine newborn by the arms, using a lifting motion, without lifting the newborn off the surface. Then release the arms suddenly. The newborn will throw the arms outward and flex the knees; the arms then return to the chest. The fingers also spread to form a C shape. The newborn initially appears startled and then relaxes to a normal resting position (see Fig. 18.17B). Assess the stepping reflex by holding the newborn upright and inclined forward with the soles of the feet touching a flat surface. The baby should make

a stepping motion or walking, alternating flexion and extension with the soles of the feet (see Fig. 18.17C). The tonic neck reflex resembles the stance of a fencer and is often called the fencing reflex. Test this reflex by having the newborn lie on the back. Turn the baby’s head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position (see Fig. 18.17D). Elicit the rooting reflex by stroking the newborn’s cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements (see Fig. 18.17E). The Babinski reflex should be present at birth and disappears at approximately 1 year of age. It is elicited by stroking the lateral sole of the newborn’s foot from the heel toward and across the ball of the foot. The toes should fan out. A diminished response indicates a neurologic problem and needs follow-up (see Fig. 18.17F). The newborn exhibits two grasp reflexes: palmar grasp and plantar grasp. Elicit the palmar grasp reflex by placing a finger on the newborn’s open palm. The baby’s hand will close around the finger. Attempting to remove the finger causes the grip to tighten. Newborns have strong grasps and can almost be lifted from a flat surface if both hands are used. The grasp should be equal bilaterally (see Fig. 18.17G). The plantar grasp is similar to the palmar grasp. Place a finger just below the newborn’s toes. The toes typically curl over the finger (see Fig. 18.17H).

FIGURE 18.17 Newborn reflexes. A. Sucking reflex. B. Moro reflex. C. Stepping reflex. D. Tonic neck reflex. E. Rooting reflex. F. Babinski reflex. G. Palmar grasp. H. Plantar grasp.

Blinking, sneezing, gagging, and coughing are all protective reflexes and are elicited when an object or light is brought close to the eye (blinking); something irritating is swallowed or a bulb syringe is used for suctioning (gagging and coughing); or an irritant is brought close to the nose (sneezing). The truncal incurvation reflex (Galant reflex) is present at birth and disappears in a few days to 4 weeks (Fig. 18.18). With the newborn in a prone position or held in ventral suspension, apply firm pressure and run a finger down either side of the spine. This stroking will cause the pelvis to flex toward the stimulated side. This indicates T2–S1 innervation. Lack of response indicates a neurologic or spinal cord problem.

FIGURE 18.18 Trunk incurvation reflex. When the paravertebral area is stroked, the newborn flexes his or her trunk toward the direction of the stimulation. (Copyright Caroline Brown, RNC, MS, DEd.)

The anocutaneous reflex (anal wink) is elicited by stimulating the perianal skin close to the anus. The external sphincter will constrict (wink) immediately with stimulation. This indicates S4–S5 innervations (Marcdante & Kliegman, 2014).

Nursing Interventions Developing confidence in caring for their newborn is challenging for most parents/significant others/partners. It takes time and patience, and a great deal of instruction provided by the nurse. “Showing and telling” parents about their newborn and all the procedures (e.g., feeding, bathing, changing, and handling) involved in daily care are key nursing interventions.

Providing General Newborn Care Generally, newborn care involves bathing and hygiene, elimination and diaper area care, cord care, circumcision care, environmental safety measures, and prevention of infection. Nurses should teach these skills to parents and should serve as role models for appropriate and consistent interaction with newborns. Demonstrating respect for the newborn and family helps foster a positive atmosphere to promote the newborn’s growth and development. BATHING AND HYGIENE Immediately after birth, drying the newborn and removing blood may minimize the risk of infection caused by hepatitis B, herpes virus, and HIV, but the specific benefits of this practice remain unclear. Until the newborn has been thoroughly bathed, standard precautions should be used when handling the newborn. Nurses need to follow their hospital policies regarding the timing and procedures for newborn bathing and hygiene. Newborns are bathed primarily for aesthetic reasons, and bathing is postponed until thermal and cardiorespiratory stability is ensured. Traditional reasons why nurses bathe the newborn are so they can conduct a physical assessment, reduce the effect of hypothermia, and allow the mother to rest (Davidson, 2014). However, recent research suggests that nurses do not need to give the newborn an initial bath to reduce heat loss; rather, the parents could be given this opportunity, supported by nurses. A study found that the amount of heat loss was similar in newborns bathed by parents versus newborns who were bathed by nurses (Davidson, 2014). Nursing Procedure 18.2 explains the steps for bathing the newborn. It is important for the nurse to wear gloves, because of potential exposure to maternal blood on the newborn, and perform the bath quickly, drying the baby thoroughly

to prevent heat loss by evaporation. After bathing, place the newborn under the radiant warmer and wrap him or her securely in blankets to prevent chilling. Check the baby’s temperature within an hour to make sure it is within normal limits. If it is low, place the newborn under a radiant heat source again. After the initial bath, the newborn may not receive another full one during the stay in the birthing unit. The diaper area will be cleansed at each diaper change, and any milk spilled into the newborn’s neck folds from breast-feeding or formula will be cleaned. Clear water and a mild soap are appropriate to cleanse the diaper area. The use of lotions, baby oil, and powders is not encouraged because oils and lotions can lead to skin irritation and can cause rashes. Powders should not be used because they can be inhaled, causing respiratory distress. If the parents want to use oils and lotions, have them apply a small amount onto their hand first, away from the newborn; this warms the lotion. Then the parents should apply the lotion or oil sparingly. Encourage the parents to gather all items needed before starting the bath: a soft, clean washcloth; two cotton balls to clean the eyes; mild, unscented soap and shampoo; towels or blankets; a tub or basin with warm water; a clean diaper; and a change of clothes. Instruct parents that a bath two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin. Parents should not fully immerse the newborn into water until the umbilical cord area is healed—up to 2 weeks after birth. Encourage parents to give the infant a sponge bath until the umbilical cord falls off and the navel area is healed completely. If the newborn has been circumcised, advise parents to wait until that area has also healed (usually 1 to 2 weeks). Until then, clean the penis with mild soap and water and apply a small amount of petroleum jelly to the tip to prevent the diaper from adhering to the penis. Instruct parents to apply the diaper loosely and place the newly circumcised male infant on his side or back to prevent pressure and irritation on the penis. Other guidelines for bathing newborns are given in Teaching Guidelines 18.1.

Teaching Guidelines 18.1

BATHING A NEWBORN

• Select a warm room with a flat surface at a comfortable working height. • Before the bath, gather all supplies needed so they will be within reach. • Never leave the newborn alone or unattended at any time during the bath. • Undress the newborn down to shirt and diaper. • Always support the newborn’s head and neck when moving or positioning him or her. • Place a blanket or towel underneath the newborn for warmth and comfort. • In this order, progressing from the cleanest to the dirtiest areas: • Wipe eyes with plain water, using either cotton balls or a washcloth. Wipe from the inner corner of the eyes to the outer with separate wipes. • Wash the rest of the face, including ears, with plain water. • Using baby shampoo, gently wash the hair and rinse with water. • Pay special attention to body creases, and dry thoroughly. • Wash extremities, trunk, and back. Wash, rinse, dry, cover. • Wash diaper area last, using soap and water, and dry; observe for rash. • Put on a clean diaper and clean clothes after the bath.

ELIMINATION AND DIAPER AREA CARE Newborn elimination patterns are highly individualized. Usually the urine is light amber in color. Soaking 6 to 12 diapers a day indicates adequate hydration. Stools can change in color, texture, and frequency without signaling a problem. Meconium is passed for the first 48 hours after birth; the stools appear thick, tarry, sticky, and dark green. Transitional stools (thin, brown to green, less sticky than meconium) typically appear by day 3 after initiation of feeding. The stool characteristics after transitional stool depend on whether the newborn is breastfed or bottle-fed. Breast-fed newborns typically pass mustard-colored, soft stool with a seedy consistency; formula-fed newborns pass yellow to brown, soft stools with a pasty consistency. As long as the newborn seems content, is eating normally, and shows no signs of illness, minor changes in bowel movements should not be a concern. The newborn needs to be checked frequently to see whether a diaper change is needed, especially after feeding. Adhere to standard precautions when providing diaper area care. Instruct parents to keep the top edge of the diaper folded down

below the umbilical cord area to prevent irritation and to allow air to help dry the cord. For a male infant, point the penis down to prevent urine from wetting the top of the diaper where the umbilicus is located.

NURSING PROCEDURE 18.2

Bathing the Newborn It is important that the nurse wear gloves, because of potential exposure to maternal blood on the newborn, and performs the bath quickly, drying the baby thoroughly to prevent heat loss by evaporation. Keep the newborn covered to prevent heat loss during the bathing procedure. 1. Begin the newborn bath starting from the cleanest area (the eyes) and proceeding to the most soiled area (the diaper area) to prevent crosscontamination. Use plain warm water on the face and eyes, adding a mild soap (e.g., Dove) to cleanse the remainder of the body. Wash, rinse, and dry each area before proceeding to the next one.

2. Wash the hair using running water so that the scalp can be thoroughly rinsed. A mild shampoo or soap can be used. Wash both fontanel areas. Frequently, parents avoid these “soft spots” because they fear that they

will “hurt the baby’s brain” if they rub too hard. Reassure parents that there is a strong membrane providing protection. Urge the parents to clean and rinse these areas well. If the anterior fontanel is not rinsed well after shampooing, cradle cap (dry flakes on the scalp) can develop. Avoid getting water in ears to prevent infection.

3. Make sure to cleanse all body creases, especially the neck folds to remove any milk that may have dripped into these areas.

4. Continue downward washing the trunk and extremities ending up with the diaper area last.

Meconium can be difficult to remove from the skin. Use plain water or special cleansing wipes if necessary to clean the area. Teach parents how to clean the diaper area properly and how to prevent skin irritation. Encourage them to avoid products such as powder and fragranced items, which could irritate the newborn’s skin. Discuss the pros and cons of using cloth diapers versus disposable diapers so that the parents can make informed decisions. Regardless of the type of diapers used, up to 10 diapers a day, or about 70 a week, will be needed. Additional information about diapering might include: • Before diapering, make sure all supplies are within reach, including clean diaper, cleaning agent or wipes, and ointment. • Lay the newborn on a changing table and remove the dirty diaper. • Use water and mild soap or wipes to gently wipe the genital area clean; wipe from front to back for girls to avoid urinary tract infections. • Wash your hands thoroughly before and after changing diapers. While performing diaper area care, parents should observe the area closely for irritation or rash. Tips for preventing or healing a diaper rash include: • Change diapers frequently, especially after bowel movements. • Apply a “barrier” cream, such as A&D ointment or Desitin, after cleaning with mild soap and water. • Use dye- and fragrance-free detergents to wash cloth diapers. • Avoid the use of plastic pants, because they tend to hold in moisture. • Expose the newborn’s bottom to air several times a day.

• Place the newborn’s buttocks in warm water after he or she has had a diaper on all night.

Take Note! Advise parents that a rash that persists for more than 3 days may be fungal in origin and may require additional treatment. Encourage the parents to notify the health care provider. CORD CARE The umbilical cord begins drying within hours after birth and is shriveled and blackened by the second or third day. Within 7 to 10 days, it sloughs off and the umbilicus heals. During this transition, frequent assessments of the area are necessary to detect any bleeding or signs of infection. Cord bleeding is abnormal and may occur if the cord clamp is loosened. Any cord drainage is also abnormal and is generally caused by infection, which requires immediate treatment. To protect the cord area during each diaper change, apply the appropriate agent (e.g., triple dye, alcohol, or an antimicrobial agent), according to facility policy, to the cord stump to prevent any ascending infections. Single-use agents for cleaning are recommended to prevent cross-contamination with other newborns. Expect to remove the cord clamp approximately 24 hours after birth by using a cord-cutting clamp. However, if the cord is still moist, keep the clamp in place and ensure a referral to home health care so that the home care nurse can remove it after discharge. Always adhere to agency policies regarding cord care; changes in policy may be necessary based on new research findings. Many parents avoid contact with the cord site to make sure they don’t “bother” it. Teach them how to care for the cord site when they go home to prevent complications (Teaching Guidelines 18.2).

Teaching Guidelines 18.2

UMBILICAL CORD CARE • Observe for bleeding, redness, drainage, or foul odor from the cord stump

and report it to your newborn’s primary care provider immediately. • Avoid tub baths until the cord has fallen off and the area has healed. • Expose the cord stump to the air as much as possible throughout the day. • Fold diapers below the level of the cord to prevent contamination of the site and to promote air-drying of the cord. • Observe the cord stump, which will change color from yellow to brown to black. This is normal. • Never pull the cord or attempt to loosen it; it will fall off naturally.

CIRCUMCISION AND CARE OF THE PENIS Circumcision is one of the oldest and most common surgical procedures performed worldwide, but remains controversial. It is performed for medical, religious, cultural, and social reasons. Circumcision is the surgical removal of all or part of the foreskin (prepuce) of the penis (Freedman & Hurwitz, 2015). This has been traditionally done for hygiene and medical reasons and is the oldest known religious rite. In the Jewish faith, circumcision is a ritual that is performed by a mohel (ordained circumciser) on the eighth day after birth if possible. The circumcision is followed by a bris (the Jewish religious ceremony), typically in the home, during which the newborn is named and symbolically enters the Jewish religious community.

FIGURE 18.19 Circumcision. A. Before the procedure. B. Clamp applied and foreskin removed. C. Appearance after circumcision.

Most other circumcisions are performed in the hospital before the newborn is

discharged as this is convenient for parents or taken to the doctor’s outpatient office after discharge, is practical, and has a demonstrated record of safety. There are three commonly used methods of circumcision: the Gomco clamp, the Hollister Plastibell device, and the Mogen clamp. During the circumcision procedure, part of the foreskin is removed by clamping and cutting with a scalpel (Gomco or Mogen clamp) or by using a Plastibell. The Plastibell is fitted over the glans, and the excess foreskin is pulled over the plastic ring. A suture is tied around the rim to apply pressure to the blood vessels, creating hemostasis. The excess foreskin is cut away. The plastic rim remains in place until healing occurs. The plastic ring typically loosens and falls off in approximately 1 week. Petroleum jelly should be applied to the circumcised area after the procedure is done with the Gomco or Mogen clamp (Sinkey et al., 2015) (Fig. 18.19). The debate over routine newborn circumcision continues in the United States. For many years, the purported benefits and harms of circumcision have been debated in the medical literature and society at large, with no clear consensus to date. Despite the controversy, circumcision is the most common surgical procedure performed on newborns, and almost two thirds (61%) of American male newborns are circumcised (CDC, 2015c). Policy Statement by American Academy of Pediatrics. A policy statement by the AAP indicates that newborn circumcision has potential disadvantages and risks as well as medical benefits and advantages. Risks to the newborn include infection, hemorrhage, skin dehiscence, adhesions, urethral fistula, and pain. Benefits to the newborn include the following: • Urinary tract infections are slightly less common in circumcised boys. However, rates are low in both circumcised and uncircumcised boys and are easily treated without long-term sequelae. • Sexually transmitted infections are less common in circumcised males, but the risk is believed to be related more to behavioral factors than to circumcision status. However, circumcised males have a 50% lower risk of acquiring HIV infection, herpes simplex virus, human papillomavirus (HPV), genital ulcer disease, bacterial vaginosis, and trichomoniasis (Tobian, Kacker, & Quinn, 2014). • There appears to be a slightly lower rate of penile cancer in circumcised males. However, penile cancer is rare and risk factors such as genital warts, infection with HPV, multiple sex partners, and cigarette smoking seem to play a much

larger role in causing penile cancer than circumcision status (Marcdante & Kliegman, 2014). The new AAP recommendations state that if parents decide to circumcise their newborn, pain relief must be provided. Research has found that newborns circumcised without analgesia experience pain and stress, indicated by changes in heart rate, blood pressure, oxygen saturation, and cortisol levels (Morrison et al., 2014). Analgesic methods may include EMLA® cream (a topical mixture of local anesthetics, lidocaine and prilocaine), a dorsal penile nerve block with buffered lidocaine, acetaminophen, skin-to-skin contact, a sucrose pacifier, and swaddling (Cunningham et al., 2014). The AAP (2015e) recommends that parents be given accurate and unbiased information about the risks and benefits of circumcision. As with other newborn procedures, research continues. Nurses must keep informed about current medical research to allow parents to make informed decisions. The absence of compelling medical evidence in favor of or against newborn circumcision makes informed consent of parents of paramount importance. The circumcision discussion involves cultural, religious, medical, and emotional considerations. Nurses may have difficulty remaining unbiased and unemotional as they present the facts to parents. Circumcision is a very personal decision for parents, and the nurse’s major responsibility is to inform the parents of the risks and benefits of the procedure and to address concerns so that the parents can reach a fully informed decision.

Take Note! The decision to circumcise the male newborn is often a social one, with the strongest factor being whether the newborn’s father is himself circumcised (Mielke, 2014). Preoperative circumcision preparation should include confirmation of the following: • Infant is at least 12 hours old or older • Infant has received standard vitamin K prophylaxis • Infant has voided normally at least once since birth

• Infant has not eaten for at least an hour prior to the procedure • Written parental consent has been obtained • Correct identification of the infant brought to the procedure room Immediately after circumcision, the tip of the penis is usually covered with petroleum-jelly–coated gauze to keep the wound from sticking to the diaper. Continued care of this site includes: • Assess for bleeding every 30 minutes for at least 2 hours. • Document the first voiding to evaluate for urinary obstruction or edema. • Squeeze soapy water over the area daily and then rinse with warm water. Pat dry. • Apply a small amount of petroleum jelly with every diaper change if the Plastibell was used; clean with mild soap and water if other techniques were used. • Fasten the diaper loosely over the penis and avoiding placing the newborn on his abdomen to prevent friction. If a Plastibell has been used, it will fall off by itself in about a week. Inform parents of this and advise them not to pull it off sooner. Also instruct the parents to check daily for any foul-smelling drainage, bleeding, or unusual swelling. If the newborn is uncircumcised, wash the penis with mild soap and water after each diaper change and do not force the foreskin back; it will retract normally over time. SAFETY Newborns are completely dependent on those around them to ensure their safety. Their safety must be ensured while in the health care facility and after they are discharged. Parental education is key, especially as the newborn grows and develops and begins to respond to and explore his or her surroundings (Teaching Guidelines 18.3).

Teaching Guidelines 18.3

GENERAL NEWBORN SAFETY • Have emergency telephone numbers readily available, such as those for emergency medical assistance and the poison control center. • Keep small or sharp objects out of reach to prevent them from being aspirated. • Put safety plugs in wall sockets within the child’s reach to prevent electrocution. • Do not leave the infant alone in any room without a portable intercom on. • Always supervise the newborn in the tub: a newborn can drown in 2 in of water. • Make sure the crib or changing table is sturdy, without any loose hardware, and is painted with lead-free paint. • Avoid placing the crib or changing table near blinds or curtain cords. • Provide a smoke-free environment for all infants. • Place all infants on their backs to sleep to prevent sudden infant death syndrome. • To prevent falls, do not leave the newborn alone on any elevated surface. • Use sun shields on strollers and hats to avoid overexposing the newborn to the sun. • To prevent infection, thoroughly wash your hands before preparing formula. • Thoroughly investigate any infant care facility before using it. Adapted from Centers for Disease Control and Prevention [CDC]. (2015d). Infants and toddlers—safety in the home and community. Retrieved from http://www.cdc.gov/parents/infants/safety.html

Environmental Safety. People who enter a health care facility for treatment expect to be safe there until they return home, but ensuring a safe environment can be a daunting challenge to a health care facility. Consider this scenario: A woman dressed in nurse’s clothing entered the hospital room of a new mother soon after she had given birth. This “nurse” told the mother that she needed to take her newborn to the nursery to have him weighed. Sometime later, a staff nurse making her routine rounds realized something was wrong when she saw that the newborn’s bassinet in the mother’s

room was empty and the mother was sound asleep in her bed. The staff nurse called security immediately because she suspected that a newborn abduction had taken place. This is a typical abduction scenario that is repeated many times throughout the United States each year. In infant abduction, someone who is not a family member takes a child less than 1 year old (NCMEC, 2015). Infant abductions are traumatic for the parents, the community, and the health care facility. The facility may also face huge financial liability if a lawsuit is filed by the parents. Abductions typically occur during the day and are usually carried out by women who are not criminally sophisticated. Many of these women experienced a pregnancy loss in the past; they are often emotionally immature and compulsive, with low self-esteem. Most female abductors can play the role of a hospital employee convincingly. Infants usually are abducted when taken for testing, during return to the nursery, when left unattended in the nursery, or while a mother was napping or showering (Joint Commission, 2015). Health care agencies are challenged to prevent infant abduction by instituting sound security practices and systems (Joint Commission, 2015). Such measures include the following: • All newborns must be transported in cribs and not carried. • Nurses must respond immediately to any security alarm that sounds on the unit. • Newborns must never be unattended at any time, especially in hallways. • All staff must wear appropriate identification at all times. • Encourage mothers to keep their baby/bassinet on their far side, away from the door. • Personnel should be wary of visitors who do not seem to be visiting a specific mother. • The electronic security system should be checked to make sure it works. • Footprint the newborn, take a color photograph, and record the newborn’s physical examination within 2 hours of birth. • Discontinue publication of birth notices in local newspapers. • Develop and implement a proactive infant abduction prevention plan. • Ensure the proper functioning and placement of any electronic sensors used on newborns. • Parents should be taught what infant abduction is; why infant security is

important; the schedule of nursery, feeding, and visiting hours; rules about visitor access; the facility’s security policies and procedures; what parents can do to protect their infant in the hospital; which staff members are allowed to handle the newborn; and what a proper ID looks like. Educating staff, educating mothers, and access control are the three key steps to preventing abductions from any health care facility. Providing a safe and secure environment is a shared responsibility of the facility, staff, and parents. Preventing abductions requires everyone to learn and follow the rules and policies. Car Safety. Every state requires the use of car seats for infants and children, because motor vehicle accidents are still the leading cause of unintentional injury and death in children under age 5. National Highway Traffic Safety Administration statistics show that nearly one half of deaths and injuries in infants occurred because they were not properly restrained. Child safety seats, when installed and used properly, can prevent injuries and save lives (AAP, 2015f). Despite evidence that the use of car seats can reduce the morbidity and mortality of motor vehicle crashes, parents who lack knowledge about them may underuse or misuse them (Hodges & Smith, 2014). Make sure that both parents understand the importance of safely transporting their newborn in a federally approved safety car seat every time the infant rides in a car. Do not release any newborn unless the parents have a car seat in place for their newborn’s ride home (Fig. 18.20). If they cannot afford one, many community organizations will provide one for them. According to the AAP’s policy statement on child passenger safety (AAP, 2015f), no one car seat is considered to be the “safest” or the “best,” but rather consistent and proper use is the key to preventing injuries and deaths. Instruct parents in the following: • Select a car seat that is appropriate for the child’s size and weight. • Caution caregivers against the placement of car seats on elevated or soft surfaces outside the car to prevent falling. • Use the car seat correctly, every time the child is in the car. • Use rear-facing car safety seats for most infants up to 2 years of age or until they reach the highest weight or height allowed by the manufacturer of their CSS.

• Make sure the harness (most seats have a three- to five-point harness) is in the slots at or below the shoulders.

FIGURE 18.20 Newborn in a properly secured car seat.

INFECTION PREVENTION The nurse plays a major role in preventing infection in the newborn environment. Ways to control infection are as follows: • Minimize exposure of newborns to organisms. • Wash your hands before and after providing care, and insist that all personnel wash their hands before handling any newborn. • Do not allow ill staff or visitors to visit or handle newborns. • Avoid sharing any infant supplies with another infant • Monitor the umbilical cord stump and circumcision site for signs of infection. • Provide eye prophylaxis by instilling prescribed medication soon after birth. • Educate parents about appropriate home measures that will prevent infections, such as practicing good hand hygiene before and after diaper changes, keeping the newborn well hydrated, avoiding taking the infant into crowds (which may expose him or her to colds and flu viruses), observing for early signs of infection (fever, vomiting, loss of appetite, lethargy, labored breathing, green watery stools, and drainage from umbilical cord site or eyes), and keeping pediatrician appointments for routine immunizations.

Promoting Sleep

Although many parents feel their newborns need them every minute of the day, babies actually need to sleep much of the day initially. Usually newborns sleep up to 15 hours daily. They sleep for 2 to 4 hours at a time but do not sleep through the night because their stomach capacity is too small to go long periods without nourishment.

Take Note! All newborns develop their own sleep patterns and cycles, but it may take several months before the newborn sleeps through the night. Frequently, newborns have their day and night hours reversed and tend to sleep more during the daytime and less during the night. Parents should place the newborn on his or her back to sleep. To prevent suffocation, all fluffy bedding, quilts, sheepskins, stuffed animals, and pillows should be removed from the crib. Parents should be informed that the practice of “co-sleeping” (sharing a bed) is not safe. For example, infants who sleep in adult beds are up to 40 times more likely to suffocate than those who sleep in cribs (AAP, 2015g). Suffocation can occur when the infant gets entangled in bedding or caught under pillows, or slips between the bed and the wall or the headboard and mattress. The parent may accidentally roll against or on top of the baby. The safest place for a newborn to sleep is in a crib, without any movable objects close by. Benefits versus risks of co-bedding, bed sharing, or co-sleeping include the following: • Benefits—Promotes breast-feeding practices; increases bonding time between the infant and mother; promotes skin-to-skin contact; and increases maternal vigilance over infant. • Risks—Increases risk for SIDS for infants younger than 4 months; risk of death if parent rolls over the infant; interrupts infant sleeping patterns; risk of asphyxia due to entrapment or airway obstruction; and unsafe design of adult beds for infants (Gaydos et al., 2014). Teach parents to avoid other unsafe conditions, such as placing the newborn in the prone position, using a crib that does not meet federal safety guidelines, allowing window cords to hang loose and in proximity to the crib, placing blankets and pillows in the crib (can potentially smother infant), exposure to

tobacco smoke, alcohol, and illicit drugs or setting the room temperature too high (can cause overheating) (CDC, 2015d). Recommendations for safe infant sleeping practices are an important aspect of education for new parents. It is important for nurses to assess families’ cultural beliefs and their prior practices to fully understand how to make recommendations in a culturally sensitive manner. The Safe to Sleep Campaign (NICHD, 2014) recommends the following to reduce the risk of SIDS: • Always place the baby on his or her back to sleep for all sleep times, including naps. • Room share—keep baby’s sleep area in the same room next to where you sleep. • Use a firm sleep surface, free from soft objects, toys, blankets, and crib bumpers.

Enhancing Bonding Encourage and enhance parent–newborn interaction by involving both parents with the baby and demonstrating appropriate nurturing behaviors: • Say “hello” and introduce yourself to the newborn. • Ask the parents’ permission to care for and hold their newborn. This helps parents to realize that they are responsible for their child and reminds nurses of their role. • Show parents the power of a soothing voice to calm the newborn (Fig. 18.21). • Provide care to the newborn in the least stressful way. • Demonstrate ways to gently wake up the newborn for better feeding. • Tell parents what you are doing, why you are doing it, and how they can duplicate what you are doing at home. • Offer the opportunity for parents to perform care while you observe them. Support their efforts to soothe the newborn throughout the care process. • Help parents to interpret the communication cues the newborn uses. • Point out the efforts the newborn is making to connect with the parents (e.g., alerting to the familiar voice, following the parents while they are speaking, quieting when held securely).

FIGURE 18.21 The father uses a soothing voice to calm the newborn.

One of the most pleasurable aspects of newborn care is being close to them. Bonding begins soon after birth when parents cradle their newborn and gently stroke him or her with their fingers. Provide parents with opportunities for “skinto-skin” contact with the newborn, holding the baby against their own skin when feeding or cradling. Many newborns respond very positively to gentle massage. If necessary, recommend books and videos that cover the subject. For newborns, crying is their only way to communicate that something is wrong. Try to find out the reason why: Is the diaper wet? Is the room too hot or too cold? Is the baby uncomfortable (e.g., diaper rash or tight clothing)? Suggest the following ways in which parents can soothe an upset newborn: • Try feeding or burping to relieve air or stomach gas. • Lightly rub the newborn’s back and speak softly to him or her. • Gently sway side to side, or rock back and forth in a rocking chair. • Talk with the newborn while making eye contact. • Take the newborn for a walk in a stroller or carriage to get fresh air. • Change the baby’s position from back to side or vice versa. • Try singing, reciting poetry and nursery rhymes, or reading to the baby.

• Turn on a musical mobile above the newborn’s head. • Give more physical contact by walking, rocking, or patting the newborn. • Swaddle the newborn to provide a sense of security and comfort. To do this: • Spread out a receiving blanket, with one corner folded slightly. • Lay the newborn face up with head at the folded corner. • Wrap the left corner over the baby’s body and tuck it beneath the baby. • Bring the bottom corner over the baby’s feet. • Wrap the right corner around the baby, leaving only the head exposed. • Arms can be released from the blanket to allow for self-comforting.

Assisting With Screening Tests Newborn screening has been among the most successful public health programs of the 21st century. Approximately 4 million infants are screened annually in the United States (Adamkin, 2015). Screening newborns for problems is important because some potentially life-threatening metabolic diseases may not be obvious at birth. Newborn screening tests that are required in most states before discharge are used to check for certain genetic and inborn errors of metabolism and hearing. Early identification and initiation of treatment can prevent significant complications and can minimize the negative effects of untreated disease. GENETIC AND INBORN ERRORS OF METABOLISM SCREENING Although each state mandates which conditions must be tested, the most common screening tests are for PKU, hypothyroidism, galactosemia, and sickle cell disease (Table 18.5). The trend toward early discharge of newborns can affect the timing of screening and the accuracy of some test results. For example, the newborn needs to ingest enough breast milk or formula to elevate phenylalanine levels for the screening test to identify PKU accurately, so newborn screening for PKU testing should not be performed before 24 hours of age. Screening tests for genetic and inborn errors of metabolism require a few drops of blood taken from the newborn’s heel (Fig. 18.22). These tests are usually performed shortly before discharge. Newborns that are discharged before 24 hours of age need to have repeat tests done within a week in an outpatient

facility. Be aware of which conditions your state regularly screens for at birth to ensure that the parents are taught about the tests and the importance of early treatment. Also be familiar with the optimal time frame for screening and conditions that could affect the results. Ensure that a satisfactory specimen has been obtained at the appropriate time and that circumstances that could cause false results have been minimized. Send out specimens and completed forms within 24 hours of collection to the appropriate laboratory (Nagtalon-Ramos, 2014). TABLE 18.5 SELECTED CONDITIONS SCREENED FOR IN THE NEWBORN

HEARING SCREENING Hearing loss is the most common birth disorder in the United States: approximately 3 to 5 newborns out of every 1,000 live births have some degree of hearing loss. Unlike a physical deformity, hearing loss is not clinically detectable at birth and thus remains difficult to assess (CDC, 2015b). Factors associated with an increased risk of hearing loss include the following: • Family history of hereditary childhood sensory hearing loss • Congenital infections such as cytomegalovirus, rubella, toxoplasmosis, or herpes

• Craniofacial anomalies involving the pinna or ear canal • Low birth weight (less than 1,500 g) • Postnatal infections such as bacterial meningitis • Head trauma • Hyperbilirubinemia requiring an exchange transfusion • Exposure to ototoxic drugs, especially aminoglycosides • Perinatal asphyxia (Nikolopoulos, 2015)

FIGURE 18.22 Screening for PKU. A. Performing a heel stick. B. Applying the blood specimen to the card for screening.

Delays in identification and intervention may affect the child’s language development, academic performance, and cognitive development. Detection

before 3 months greatly improves outcomes. Because of this, auditory screening programs for all newborns are recommended by the AAP (2015d) and are mandated by law in over 30 states. Screening only infants with risk factors is not enough, because as many as 50% of infants born with hearing loss have no known risk factors (CDC, 2015b). Early identification and intervention can prevent severe psychosocial, educational, and language development delays. The current goals of Healthy People 2020 (USDHHS, 2010) are to screen all infants by 1 month of age, confirm hearing loss with an audiologic examination by 3 months of age, and treat with comprehensive early intervention services before 6 months of age (see the Healthy People 2020 feature earlier in this chapter and Box 18.1 for screening methods). All newborns should be screened prior to discharge to ensure that any newborn with a hearing loss is not missed. Those with suspected hearing loss should be referred for follow-up assessment. In addition, nurses should ensure that testing is accurate to facilitate early diagnosis and intervention services and to optimize the newborn’s developmental potential. The implementation of newborn hearing screenings has lowered the mean age of hearing loss identification and many deaf children are now diagnosed in the early age of months old.

BOX 18.1 NEWBORN HEARING SCREENING METHODS Newborn hearing screening is the standard of care in hospitals nationwide. The primary purpose of newborn hearing screening is to identify newborns who are likely to have a hearing loss and who require further evaluation. A newborn’s hearing can be screened in one of two ways: otoacoustic emission (OAE) or automated auditory brainstem response (ABR). In OAE, an earphone is placed in the infant’s ear canal and the sounds produced by the newborn’s inner ear are measured in response to certain tones or clicks presented through the earphone. Preset parameters in the equipment decide whether the OAEs are sufficient for the newborn to pass or whether a referral is necessary for further evaluation. In ABR, an earphone is placed in the ear canal or an earmuff is placed over the newborn’s ear, and a soft, rapid tapping noise is presented. Electrodes placed around the newborn’s head, neck, and shoulders record neural activity from the infant’s brainstem in response to the tapping noises. The ABR tests how well the ear and the nerves leading to the brain work. Like OAEs, automated ABR screening is sensitive to more than mild degrees of hearing loss, but a “pass” does not guarantee normal hearing. Adapted from Mersch, J., Kibby, J. E., & Bredenkamp, J. K. (2014). Newborn infant hearing screening. MedicineNet.com,

Retrieved

http://www.medicinenet.com/newborn_infant_hearing_screening/article.htm;

from American

Speech-

Language-Hearing Association [ASHA]. (2014). Newborn infant hearing screening. Retrieved from http://www.asha.org/Practice-Portal/Professional-Issues/Newborn-Infant-Hearing-Screening/;

and

American Academy of Pediatrics [AAP]. (2015d). Purpose of newborn hearing screening. Retrieved from

http://www.healthychildren.org/English/ages-stages/baby/Pages/Purpose-of-Newborn-Hearing-

Screening.aspx

Common Concerns During the newborn period of transition, certain conditions can develop that require intervention. These conditions, although not typically life threatening, can be a source of anxiety for the parents. Common concerns include transient

tachypnea of the newborn, physiologic jaundice, and hypoglycemia. TRANSIENT TACHYPNEA OF THE NEWBORN Transient tachypnea of the newborn appears soon after birth. It occurs when the fetal liquid in the lungs is removed slowly or incompletely. This can be due to the lack of thoracic squeezing that occurs during a cesarean birth or diminished respiratory effort if the mother received central nervous system depressant medication. Prolonged labor, macrosomia of the fetus, and maternal asthma also have been associated with this condition. A vaginal birth appears to be protective against transient tachypnea of the newborn (Cunningham et al., 2014). Transient tachypnea is accompanied by retractions; expiratory grunting or cyanosis and is relieved by low-dose oxygen therapy. Mild or moderate respiratory distress typically is present at birth or within 6 hours of birth. Transient tachypnea of the newborn is generally a self-limited disorder without significant morbidity. Transient tachypnea of the newborn resolves over a 24hour to 72-hour period. Nursing interventions include providing supportive care: giving oxygen, ensuring warmth, observing respiratory status frequently, and allowing time for the pulmonary capillaries and the lymphatics to remove the remaining fluid. The clinical course is relatively benign, but any newborn respiratory issue can be very frightening to the parents. Provide a thorough explanation and reassure them that the condition will resolve over time. PHYSIOLOGIC JAUNDICE Physiologic jaundice is very common in newborns, with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life. In any given year, approximately 65% of the newborns in the United States will experience clinical jaundice (King et al., 2015). Jaundice is the visible manifestation of hyperbilirubinemia. It typically results from the deposition of unconjugated bilirubin pigment in the skin and mucous membranes. Physiologic jaundice can be best understood as an imbalance between the production and elimination of bilirubin, with a multitude of factors and conditions affecting each of these processes. When an imbalance results because of an increase in circulating bilirubin (or the bilirubin load) to significantly high levels, it may go on to cause acute neurologic sequelae (acute bilirubin encephalopathy). In most infants, an increase in bilirubin production (e.g., due to

hemolysis) is the primary cause of physiologic jaundice, and thus reducing bilirubin production is a rational approach for its management. Factors that contribute to the development of physiologic jaundice in the newborn include an increased bilirubin load because of relative polycythemia, a shortened erythrocyte life span (80 days compared with the adult 120 days), and immature hepatic uptake and conjugation processes (Chu, 2014). Normally the liver removes bilirubin from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn’s liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing a yellowish discoloration on the skin. AAP Guidelines for Prevention and Management of Hyperbilirubinemia in Newborns. The AAP has recently released guidelines for the prevention and management of hyperbilirubinemia in newborns: • Promote and support successful breast-feeding practices to make sure the newborn is well hydrated and stooling frequently to promote elimination of bilirubin. • Advise mothers to nurse their infants at least 8 to 12 times per day for the first several days. • Avoid routine supplementation of nondehydrated breast-fed infants with water or dextrose water because that will not lower bilirubin levels. • Ensure that all infants are routinely monitored for the development of jaundice and that nurseries have established protocols for the assessment of jaundice. Jaundice should be assessed whenever the infant’s vital signs are measured but no less than every 8 to 12 hours. • Before discharge, complete a systematic assessment for the risk of severe hyperbilirubinemia. • Provide early and focused follow-up based on the risk assessment. • When indicated, treat newborns with phototherapy or exchange transfusion to prevent acute bilirubin encephalopathy (AAP, 2015h). In newborn infants, jaundice can be detected by blanching the skin with digital pressure on the bridge of the nose, sternum, or forehead, revealing the underlying color of the skin and subcutaneous tissue. If jaundice is present, the blanched area will appear yellow before the capillary refill. The assessment of jaundice must be performed in a well-lit room or, preferably, in daylight at a

window. Jaundice is usually seen first in the face and progresses caudally to the trunk and extremities (AAP, 2015h). Measures that parents can take to reduce the risk of jaundice include exposing the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin, providing breast-feeding on demand to promote elimination of bilirubin through urine and stooling, and avoiding glucose water supplementation, which hinders elimination. If or when the levels of unconjugated serum bilirubin increase and do not return to normal levels with increased hydration, phototherapy is used. The serum level of bilirubin at which phototherapy is initiated is a matter of clinical judgment by the physician, but it is often begun when bilirubin levels reach 12 to 15 mg/dL in the first 48 hours of life in a term newborn (Davidson, 2014). Phototherapy involves exposing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted through feces and urine. Phototherapy is the most common treatment for hyperbilirubinemia and has virtually eliminated the need for exchange transfusions in newborns now.

Take Note! Exposure of newborns to sunlight represents the first documented use of phototherapy in the medical literature. Sister J. Ward, a charge nurse in Essex, England, recognized in 1956 that when jaundiced newborns were exposed to the sun they became less yellow. This observation changed the entire treatment of jaundice in newborns (Maisels, 2015). Phototherapy reduces bilirubin levels in the blood by breaking down unconjugated bilirubin into colorless compounds. These compounds can then be excreted in the bile. Phototherapy aims to curtail the increase in bilirubin blood levels; thereby preventing kernicterus, a condition in which unconjugated bilirubin enters the brain. If not treated, kernicterus can lead to brain damage and death. During the past several decades, phototherapy has generally been administered with either banks of fluorescent lights or spotlights. Factors that determine the dosage of phototherapy include spectrum of light emitted, irradiance of light source, design of light unit, surface area of newborn exposed

to the light, and distance of the newborn from the light source (McDermott, 2015). For phototherapy to be effective, the rays must penetrate as much of the skin as possible. Thus, the newborn must be naked and turned frequently to ensure maximum exposure of the skin. Several side effects of standard phototherapy have been identified: frequent loose stools, increased insensible water loss, transient rash, and potential retinal damage if the newborn’s eyes are not covered sufficiently. Recently, fiberoptic pads (Biliblanket or Bilivest) have been developed that can be wrapped around the newborn or on which the newborn can lie. The light is delivered from a tungsten–halogen bulb through a fiber-optic cable and is emitted from the sides and ends of the fibers inside a plastic pad (Plavskii, Tret’yakova, & Mostovnikova, 2014). These products work on the premise that phototherapy can be improved by delivering higher-intensity therapeutic light to decrease bilirubin levels. The pads do not produce appreciable heat like the banks of lights or spotlights do, so insensible water loss is not increased. Eye patches also are not needed; thus, parents can feed and hold their newborns continuously to promote bonding. When caring for newborns receiving phototherapy for jaundice, nurses must do the following: • Closely monitor body temperature and fluid and electrolyte balance. • Document frequency, character, and consistency of stools. • Monitor hydration status (weight, specific gravity of urine, and urine output). • Turn frequently to increase the infant’s skin exposure to phototherapy. • Observe skin integrity (as a result of exposure to diarrhea and phototherapy lights). • Provide eye protection to prevent corneal injury related to phototherapy exposure. • Encourage parents to participate in their newborn’s care to prevent parent– infant separation. See Chapter 24 for a more detailed discussion of hyperbilirubinemia. The home health nurse made a postpartum visit to Kelly to assess the situation. Kelly’s son was slightly jaundiced when the home health nurse pressed gently over his sternum, but Kelly said he was nursing better

compared with the previous 2 days. What home suggestions can the nurse make to Kelly to reduce the jaundice? What specific education about physiologic jaundice is needed? HYPOGLYCEMIA During the first 24 to 48 hours of life, as normal newborns transition from intrauterine to extrauterine life, their plasma glucose levels are typically lower than later in life. Hypoglycemia affects as many as 40% of all full-term newborns. It is defined as a blood glucose level of less than 30 mg/dL or a plasma concentration of less than 40 mg/dL in the first 72 hours of life (Thornton et al., 2015). From a physiologic perspective, a newborn may be said to be hypoglycemic when glucose supply is inadequate to meet demand. In newborns, blood glucose levels fall to a low point during the first few hours of life because the source of maternal glucose is removed when the placenta is expelled. This period of transition is usually smooth, but certain newborns are at greater risk for hypoglycemia: infants of mothers who have diabetes, preterm newborns, and newborns with intrauterine growth restriction (IUGR), inadequate caloric intake, sepsis, asphyxia, hypothermia, polycythemia, glycogen storage disorders, and endocrine deficiencies (Adamkin, 2015). Most newborns experience transient hypoglycemia and are asymptomatic. The symptoms, when present, are nonspecific and include jitteriness, lethargy, cyanosis, apnea, seizures, high-pitched or weak cry, hypothermia, and poor feeding. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur (Stanley et al., 2015). Treatment of hypoglycemia in the newborn includes administration of a rapidacting source of glucose such as a sugar/water mixture or early formula-feeding. In acute, severe cases, intravenous administration of glucose may be required. Continuous monitoring of glucose levels is not only prudent but mandatory in high-risk newborns. Although there is no specific means of preventing hypoglycemia in newborns, it is wise and cautious to monitor for symptoms and intervene as soon as symptoms are noted. Subsequently, early diagnosis and appropriate intervention are essential for all newborns. Nursing care of the hypoglycemic newborn includes monitoring for signs of hypoglycemia or identifying high-risk newborns prone to this disorder based on their perinatal history, physical examination, body measurements, and

gestational age. Glucose screening should be performed only on at-risk infants and those with clinical symptoms compatible with hypoglycemia (National Guideline Clearinghouse, 2015). Prevent hypoglycemia in newborns at risk by initiating early feedings with breast milk or formula. If hypoglycemia persists despite feeding, notify the primary health care provider for orders such as intravenous therapy with dextrose solutions. Anticipate hypoglycemia in certain high-risk newborns and begin assessments immediately on nursery admission.

Promoting Nutrition Several physiologic changes dictate the type and method of feeding throughout the newborn’s first year. Some of these changes include the following: • Stomach capacity is limited at birth. The emptying time is short (2 to 3 hours) and peristalsis is rapid. Therefore, small, frequent feedings are needed at first, with amounts progressively increasing with maturity. • The immune system is immature at birth, so the baby is at a high risk for food allergies during the first 4 to 6 months of life. Introducing solid foods prior to this time increases the risk of developing food allergies. • Pancreatic enzymes and bile to assist in digestion of fat and starch are in limited supply until about 3 to 6 months of age. Infants cannot digest cereal prior to this time. • The kidneys are immature and unable to concentrate urine until about 4 to 6 weeks of age. Excess protein and mineral intake can place a strain on kidney function and can lead to dehydration. Infants need to consume more water per unit of body weight than adults do as a result of their high body weight from water. • Immature muscular control at birth changes over time to assist in the feeding process by improving head and neck control, hand–eye coordination, swallowing, and ability to sit, grasp, and chew. At about 4 to 6 months, inborn reflexes disappear, head control develops, and the infant can sit to be fed, making spoon-feeding possible (Dudek, 2014) NEWBORN NUTRITIONAL NEEDS As newborns grow, their energy and nutrient requirements change to meet their body’s changing needs. During infancy, energy, protein, vitamin, and mineral

requirements per pound of body weight are higher than at any other time of life. These high levels are needed to fuel the rapid growth and development during this stage of life. Generally, an infant’s birth weight doubles in the first 4 to 6 months of life and triples within the first year (Walker, 2014). A newborn’s caloric needs range from 110 to 120 cal/kg body weight. Breast milk and formulas contain approximately 20 cal/oz, so the caloric needs of young infants can be met if several feedings are given throughout the day. Most term infants need a basic formula if the mother chooses not to breast-feed. These formulas are modeled after breast milk, which contains 20 cal/oz. There is no evidence to recommend one brand over the other since all of them are nutritionally interchangeable. All formulas are classified based on three parameters: caloric density, carbohydrate source, and protein composition (see Table 18.6). Fluid requirements for the newborn and infant range from 100 to 150 mL/kg daily. This requirement can be met through breast- or bottle-feeding. Additional water supplementation is not necessary. Adequate carbohydrates, fats, protein, and vitamins are achieved through consumption of breast milk or formula. The AAP (2015i) recommends that bottle-fed infants be given iron supplementation, because iron levels are low in all types of formula milk. This can be achieved by giving iron-fortified formula from birth. The breast-fed infant draws on iron reserves for the first 6 months and then needs iron-rich foods or supplementation added at 6 months of age. The AAP (2015i) also has recommended that all infants (breast- and bottle-fed) receive a daily supplement of 400 IU of vitamin D starting within the first few days of life to prevent rickets and vitamin D deficiency. It is also recommended that fluoride supplementation be given to infants not receiving fluoridated water after the age of 6 months (AAP, 2015i). Recently, the AAP recommended that all pregnant and lactating women use iodized salt and take a supplement of 150 μg of iodine daily. An iodine deficiency can affect fetal and early childhood neurocognitive development (AAP, 2015j). SUPPORTING THE CHOICE OF FEEDING METHOD The benefits of breast-feeding are significant and well documented. Numerous health-related professional organizations promote breast-feeding because of the health benefits for both the mother and infant. Nurses should encourage and advocate breast-feeding for their clients and provide support for the family throughout their breast-feeding experiences. Parents typically decide about the

method of feeding well before the infant is born. Prenatal and childbirth classes present information about breast-feeding versus bottle-feeding and allow the parents to make up their minds about which method is best for them. Various factors can influence their decision, including socioeconomic status, culture, sexual objectification, fear of a negative community reaction, personal inconvenience, dietary restrictions, lack of social support, lack of self-efficacy, high frequency of violence, employment, level of education, lack of access to breast pumps, lack of time, free formula provided by government programs, range of care interventions provided during pregnancy, childbirth, and the early postpartum period, and especially partner support (Dunn et al., 2015). Nurses can provide evidence-based information to assist the couple in making their decision. Regardless of which method is chosen, the nurse needs to respect and support the couple’s decision. TABLE 18.6 COMPARISON OF BREAST MILK WITH SELECTED FORMULA COMPOSITION

FEEDING THE NEWBORN The newborn can be fed at any time during the transition period if assessments are normal and a desire is demonstrated. Before the newborn can be fed, determine his or her ability to suck and swallow. Clear any mucus in the nares or mouth with a bulb syringe before initiating feeding. Auscultate bowel sounds, check for abdominal distention, and inspect the anus for patency. If these parameters are within normal limits, newborn feeding may be started. Most newborns are on demand feeding schedules and are allowed to feed when they awaken. When they go home, mothers are encouraged to feed their newborns every 2 to 4 hours during the day and only when the newborn awakens during the night for the first few days after birth. Parents often have many questions about feeding. Generally, newborns should be fed on demand whenever they seem hungry. Most newborns will give clues about their hunger status by crying, placing their fingers or fist in their mouth, rooting around, and sucking.

Newborns differ in their feeding needs and preferences, but most breast-fed ones need to be fed every 2 to 3 hours, nursing for 10 to 20 minutes on each breast. The length of feedings is up to the mother and newborn. Encourage the mother to respond to cues from her infant and not feed according to a standard or preset schedule. Formula-fed newborns usually feed every 3 to 4 hours, finishing a bottle in 30 minutes or less. Daily formula intake for an infant should be 1.5 to 2 oz/lb of body weight, but growth is a better measure of health than the amount of formula consumed (Schlenker & Gilbert, 2015). If the newborn seems satisfied, wets 6 to 10 diapers daily, produces several stools a day, sleeps well, and is gaining weight regularly, then he or she is probably receiving sufficient breast milk or formula. Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent this by burping them frequently throughout the feeding. Tips about burping include: • Hold the newborn upright with his or her head on the parent’s shoulder (Fig. 18.23A). • Support the head and neck while the parent gently pats or rubs the newborn’s back (Fig. 18.23B). • Have the newborn sit on the parent’s lap, while supporting the baby’s chest and head. Gently rub the newborn’s back with the other hand. • Lay the newborn on the parent’s lap with the baby’s back facing up. • Support the newborn’s head in the crook of the parent’s arm and gently pat or rub the back.

Take Note! It is the upright position, not the strength of the patting or rubbing that allows the newborn to release air accumulated in the stomach.

FIGURE 18.23 The nurse demonstrates (A) holding the newborn upright over the shoulder and (B) sitting the newborn upright, supporting the neck and chin.

Stress to parents that feeding time is more than an opportunity to get nutrients into their newborn; it is also a time for closeness and sharing. Feedings are as much for the baby’s emotional pleasure as his or her physical well-being. Encourage parents to maintain eye contact with the newborn during the feeding, hold him or her comfortably close to them, and talk softly during the feeding to promote closeness and security. BREAST-FEEDING There is consensus in the medical community that breast-feeding is optimal for all newborns. The AAP and the American Dietetic Association recommend breast-feeding exclusively for the first 6 months of life, continuing it in conjunction with other food at least until the newborn’s first birthday. An estimated 75% of American mothers attempt to breast-feed, but just 13% are able to exclusively by 6 months (Busch, Logan, & Wilkinson, 2014). Box 18.2 highlights the advantages of breast-feeding for the mother and newborn. In addition, breast-feeding is associated with lower incidence of necrotizing enterocolitis and diarrhea during the early period of life and with lower incidence of inflammatory bowel diseases, type 2 diabetes, and obesity later in life (Martin, Fanaroff, & Welsh, 2014). Mothers should continue to breast-feed during mild illnesses such as colds or flu. However, in the United States mothers with HIV are advised not to breast-feed.

BOX 18.2 ADVANTAGES OF BREAST-FEEDING

Advantages for the Newborn • Contributes to the development of a strong immune system • Stimulates growth of positive bacteria in digestive tract • Reduces incidence of stomach upset, diarrhea, and colic • Begins the immunization process at birth by providing passive immunity • Promotes optimal mother–infant bonding • Reduces risk of newborn constipation • Promotes greater developmental gains in preterm infants • Provides easily tolerated and digestible formula that is sterile, at proper temperature, and readily available with no artificial colorings, flavorings, or preservatives • Is less likely to result in overfeeding, leading to obesity • Promotes better tooth and jaw development as a result of sucking hard • Provides protection against food allergies • Lowers health care costs due to fewer illnesses • Is associated with avoidance of type 1 diabetes and heart disease

Advantages for the Mother • Can facilitate postpartum weight loss by burning extra calories • Stimulates uterine contractions to control bleeding • Lowers risk for ovarian and endometrial cancers • Facilitates bonding with newborn infant • Lowers risk of type 2 diabetes • Breast milk is free verses formula costs. • Reduces risk of postpartum depression • Promotes uterine involution as a result of release of oxytocin • Lowers the risk of breast cancer and osteoporosis • Affords some protection against conception, although it is not a reliable contraceptive method Data from Schlenker, E., & Gilbert, J. A. (2015). William’s essentials of nutrition and diet therapy (11th ed.). St. Louis, MO: Mosby Elsevier; Christopher, G. C., & Krell, J. K. (2014). Changing the breastfeeding conversation and our culture. Breastfeeding Medicine, 9(2), 53–55; and Walker, M. (2014). Breastfeeding management for the clinician: Using the evidence (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

The composition of breast milk changes over time from colostrum to transitional milk, and finally to mature milk. Colostrum is a thick, yellowish substance secreted during the first few days after birth. It is high in protein, minerals, and fat-soluble vitamins. It is rich in immunoglobulins A, which help protect the newborn’s gastrointestinal tract against infections. It is a natural laxative that helps rid the intestinal tract of meconium quickly (Gephart & Weller, 2014). Transitional milk occurs between colostrum and mature milk and contains all the nutrients in colostrum, but it is thinner and less yellow than colostrum. This transitional milk is replaced by true or mature milk around day 10 after birth. Mature milk appears bluish and is not as thick as colostrum. It provides 20 cal/oz and contains the following:

• Protein—Although the content is lower than formula, it is ideal to support growth and development for the newborn. The majority of the protein is whey, which is easy to digest. • Fat—Approximately 58% of total calories are fat, but they are easy to digest. Essential fatty acid content is high, as is the level of cholesterol, which helps develop enzyme systems capable of handling cholesterol later in life. • Carbohydrate—Approximately 35% to 40% of total calories are in the form of lactose, which stimulates the growth of natural defense bacteria in the gastrointestinal system and promotes calcium absorption. • Water—Water, the major nutrient in breast milk, makes up 85% to 95% of the total volume. Total milk volume varies with the age of the infant and demand. • Minerals—Breast milk contains calcium, phosphorus, chlorine, potassium, and sodium, with trace amounts of iron, copper, and manganese. Iron absorption is about 50%, compared with about 4% for iron-fortified formulas. • Vitamins—All vitamins are present in breast milk; vitamin D is the lowest in amount. Vitamin D supplementation is recommended by the AAP now. • Enzymes—Lipase and amylase are found in breast milk to assist with digestion (Dudek, 2014). Breast-Feeding Assistance. Breast-feeding can be initiated immediately after birth. If the newborn is healthy and stable, wipe the newborn from head to toe with a dry cloth and place him or her skin to skin on the mother’s abdomen. Then cover the newborn and mother with another warmed blanket to hold in the warmth. Immediate mother–newborn contact takes advantage of the newborn’s natural alertness after a vaginal birth and fosters bonding. This immediate contact also reduces maternal bleeding and stabilizes the newborn’s temperature, blood glucose level, and respiratory rate (Khan et al., 2015). Left alone on the mother’s abdomen, a healthy newborn scoots upward, pushing with the feet, pulling with the arms, and bobbing the head until finding and latching on to the mother’s nipple. A newborn’s sense of smell is highly developed, which also helps in finding the nipple. As the newborn moves to the nipple, the mother produces high levels of oxytocin, which contracts the uterus, thereby minimizing bleeding. Oxytocin also causes the breasts to release colostrum when the newborn sucks on the nipple. Colostrum is rich in antibodies and thus provides the newborn with her “first immunization” against infection. Keys to successful breast-feeding include:

• Initiating breast-feeding within the first hour of life if the newborn is stable • Placing the newborn on the mother’s chest/abdomen immediately after birth • Following the newborn’s feeding schedule—8 to 12 times in 24 hours • Providing unrestricted periods of breast-feeding • Offering no supplement unless medically indicated • Having a lactation consultant observe a feeding session • Avoiding artificial nipples and pacifiers except during a painful procedure • Increasing fluid intake to encourage greater milk production (Evidence-Based Practice Box 18.1) • Feeding from both breasts over each 24-hour period • Watching for indicators of sufficient intake from infant: • Six to ten wet diapers daily • Waking up hungry 8 to 12 times in 24 hours • Acting content and falling asleep after feeding • Keeping the newborn with the mother throughout the hospital stay • The nurse or lactation consultant should be available to guide and support the breast-feeding mother while on the postpartum unit

EVIDENCE-BASED PRACTICE 18.1 PRIMARY CARE SETTING: A COMMUNITY PILOT PROJECT APPLYING THE TRI-CORE BREAST-FEEDING MODEL: BEYOND THE BASICS

STUDY Ongoing evidence-based practice findings strongly indicate that the lifelong health and economic benefits of breast-feeding contributes greatly to the health status of the infant, the mother, the family, and the society at large. Promotional lactation interventions are needed in the community to initiate and foster breast-feeding efforts beyond the hospital after discharge. The purpose of this study was to develop a primary care breast-feeding support program, bridging the gap from hospital discharge into primary care to improve breast-feeding rates. The study incorporated the three core interventions of the Tri-Core model: (1) Improving lactation support; (2) enhancing maternal and staff lactation education; and (3) fostering maternal confidence in their ability to breast-feed.

Findings The study population (N = 50) included middle- to low-income families that had recently given birth to a healthy full-term infant who desired to breastfeed within the early postpartum period. Outcomes were measured by the assessment of breast-feeding rates, durations, and reported maternal selfefficacy levels at 1 month, and a 2-month visit. Ongoing office support was provided with lactation visits and phone calls. Findings indicated significant gains in all three areas especially in overall breast-feeding rates when compared to previous rates, especially in rates of exclusive breast-feeding.

Nursing Implications Based on the results of this study, nurses should remain instrumental in promoting successful breast-feeding practices by initiating breast-feeding as soon as possible after birth, assisting the mother to find a comfortable position for breast-feeding, assessing the infant’s latch on to the mother’s breast, and reassuring her that the infant is getting adequate amount of breast milk. In addition, utilizing multiprofessional community resources to encourage and support continued breast-feeding efforts is essential. Community referrals are important to help support the novice breast-feeding mother to reinforce breast-feeding instruction once she is discharged from the hospital. Nurses involved in improving breast-feeding rates benefits all ages and its greatest impact will be improving short- and long-term health care outcomes for all families. Adapted from Busch, D., Nassar, L., & Silbert-Flagg, J. (2015). The necessity of breastfeeding– promoting breastfeeding in the primary care setting; A community pilot project applying the Tri-Core Breastfeeding Model: Beyond the basics. Journal of Pregnancy & Child Health, 2(3), 2–7.

Help position the newborn so that latching-on is effective and is not painful for the mother. Placing pillows or a folded blanket under the mother’s head may help, or rolling her to one side and tucking the newborn next to her. Assess both the mother and newborn during this initial session to determine needs for assistance and education. One tool used frequently in this assessment is the LATCH scoring tool (Abbas & Hasan, 2015). The LATCH scoring tool is a breast-feeding charting system that provides a systematic method for gathering information about individual breast-feeding sessions. The system assigns a numerical score of 0, 1, or 2 to five key components of breast-feeding. Each letter of the acronym LATCH denotes an area of assessment: “L” is for how well the infant latches onto the breast; “A” is for the amount of audible swallowing noted; “T” is for the mother’s nipple type; “C” is for the mother’s level of comfort; “H” is for the amount of help the mother needs to hold her infant to the breast. The system is visually represented in the same form as the Apgar scoring grid, and the numbers are handled in the same way. With the LATCH system, the nurse can assess maternal and infant variables, define areas of needed

intervention, and determine priorities in providing client care and teaching (Table 18.7). The higher the score, the lesser the nursing intervention needed by the mother and baby. Breast-Feeding Positioning. The mother and infant must be in comfortable positions to ensure breast-feeding success. The four most common positions for breast-feeding are the football, cradle, across-the-lap, and side-lying holds. Each mother, on experimentation, can decide which positions feel most comfortable for her (Fig. 18.24). • In the football hold, the mother holds the infant’s back and shoulders in her palm and tucks the infant under her arm. Remind the mother to keep the infant’s ear, shoulder, and hip in a straight line. The mother supports the breast with her hand and brings it to the infant’s lips to latch on. She continues to support the breast until the infant begins to nurse. This position allows the mother to see the infant’s mouth as she guides her infant to the nipple. This is a good choice for mothers who have had a cesarean birth because it avoids pressure on the incision. • The cradling position is the one most commonly used. The mother holds the baby in the crook of her arm, with the infant facing the mother. The mother supports the breast with her opposite hand. • In the across-the-lap position, the mother places a pillow across her lap, with the infant facing the mother. The mother supports the infant’s back and shoulders with her palm and supports her breast from underneath. After the infant is in position, the infant is pulled forward to latch on. • In the side-lying position, the mother lies on her side with a pillow supporting her back and another pillow supporting the newborn in the front. To start, the mother props herself up on an elbow and supports the newborn with that arm, while holding her breast with the opposite hand. Once nursing is started, the mother lies down in a comfortable position. To promote latching-on, instruct the mother to make a C or a V shape with her fingers. In the C hold, the mother places her thumb well above the areola and the other four fingers below the areola and under the breast. In the V hold, the mother places her index finger above the areola and her other three fingers below the areola and under the breast. Either method can be used as long as the mother’s hand is well away from the nipple so the infant can latch on.

TABLE 18.7 THE LATCH SCORING TOOL

FIGURE 18.24 Breast-feeding positions.

Breast-Feeding Education. Breast-feeding is not an innate skill in human mothers. Almost all women have the potential to breast-feed successfully, but many fail because of inadequate knowledge. Nursing Care Plan 18.1 gives typical nursing diagnoses, outcomes, and interventions. For many mothers and newborns, breast-feeding goes smoothly from the start, but for others it is a struggle. Nurses can help throughout the experience by not being judgmental and by demonstrating techniques and offering encouragement and praise for success. Correct positioning will enhance good attachment and will ensure effective milk transfer. Nurses should emphasize that the key to successful breast-feeding is correct positioning and latching-on. Teaching by nurses has been shown to have a significant effect on both the ability to breast-feed successfully and the duration of lactation (Dudek, 2014). During the first few breast-feeding sessions, mothers want to know how often they should be nursing, whether breast-feeding is going well, if the newborn is getting enough nourishment, and what problems may ensue and how to cope with them. Education for the breast-feeding mother is highlighted in Teaching Guidelines 18.4.

Take Note! Remember that the supply of milk is equal to the demand—the more sucking, the more milk. Remember Kelly, who was concerned about jaundice in her newborn son? At her son’s 2-week well-baby checkup at the clinic, his bilirubin level came back within normal limits. Kelly still felt he was not getting enough to eat and stated that she might switch to formula-feeding her son. What information can the nurse present to promote and reinforce breast-feeding? Should the nurse make a referral to the lactation consultant?

NURSING CARE PLAN 18.1 Overview of the Mother and Newborn Having Difficulty With BreastFeeding Baby boy James, weight 7 lb, 4 oz, was born a few hours ago. His mother, Jane, is a 19-year-old gravida 1, para 1[AQ8]. His Apgar scores were 9 points at both 1 and 5 minutes. Labor and birth were unremarkable, and James was admitted to the nursery for assessment. After stabilization, James was brought to his mother, who had said she wished to breast-feed. The postpartum nurse assisted the new mother with positioning and latching-on and left the room for a few minutes. On returning, the mother was upset, James was crying, and she stated she wanted a bottle of formula to feed him since she didn’t have milk and her nipples hurt. Assessment reveals a young, inexperienced mother placed in an uncomfortable situation with limited knowledge of breast-feeding. Anxiety from the mother transferred to James, resulting in crying. The mother, apprehensive about breast-feeding, needs additional help. NURSING DIAGNOSIS: Ineffective breast-feeding related to pain and limited skill Outcome Identification and Evaluation The mother will demonstrate understanding of breast-feeding skills as evidenced by use of correct positioning and technique, and verbalization of appropriate information related to breast-feeding. Interventions: Providing Education • Instruct the mother on proper positioning for breast-feeding; suggest use of football hold, side-lying position, modified cradle, and across-the-lap position to ensure comfort and to promote ease in breast-feeding. • Review breast anatomy and milk letdown reflex to enhance mother’s understanding of lactation. • Observe newborn’s ability to suck and latch on to the nipple to assess whether newborn has adequate ability. • Monitor sucking and newborn swallowing for several minutes to ensure

adequate latching on and to assess intake. • Reinforce nipple care with water and exposure to air to maintain nipple integrity. NURSING DIAGNOSIS: Anxiety related to breast-feeding ability and irritable, crying newborn Outcome Identification and Evaluation The mother will verbalize increased comfort with breast-feeding as evidenced by positive statements related to breast-feeding and verbalization of desire to continue to breast-feed newborn. Interventions: Reducing Anxiety • Ensure that the environment is calm and soothing without distractions to promote maternal and newborn relaxation. • Show the mother correct latching-on technique to promote breast-feeding. • Assist in calming newborn by holding and talking to ensure that the newborn is relaxed prior to latching on. • Reassure the mother she can be successful at breast-feeding to enhance her self-esteem and confidence. • Encourage frequent trials and attempts to enhance confidence. • Encourage the mother to verbalize her anxiety/fears to reduce anxiety. NURSING DIAGNOSIS: Pain related to breast-feeding and incorrect latching-on technique Outcome Identification and Evaluation The mother will experience a decrease in pain during breast-feeding as evidenced by statements of less nipple pain. Interventions: Reducing Pain • Suggest several alternate positions for breast-feeding to increase comfort. • Demonstrate how to break suction before removing infant from breast to minimize trauma to nipple. • Inspect nipple area to promote early identification of trauma. • Reinforce correct latching-on technique to prevent nipple trauma. • Administer pain medication if indicated to relieve pain.

• Instruct about nipple care between feedings to maintain nipple integrity.

Teaching Guidelines 18.4

BREAST-FEEDING • Set aside a quiet place where you can be relaxed and won’t be disturbed. Relaxation promotes milk letdown. • Sit in a comfortable chair or rocking chair or lie on a bed. Try to make each feeding calm, quiet, and leisurely. Avoid distractions. • Listen to soothing music and sip a nutritious drink during feedings. • Initially, nurse the newborn every few hours to stimulate milk production. Remember that the supply of milk is equal to the demand—the more sucking, the more milk. • Watch for signals from the infant to indicate that he or she is hungry, such as: • Nuzzling against the mother’s breasts • Demonstrating the rooting reflex by making sucking motions • Placing fist or hands in mouth to suck on • Crying and squirming • Smacking the lips • Stimulate the rooting reflex by touching the newborn’s cheek to initiate sucking. • Look for signs indicating that the newborn has latched on correctly: wideopen mouth with the nipple and much of the areola in the mouth, lips rolled outward, and tongue over lower gum, visible jaw movement drawing milk out, rhythmic sucking with an audible swallowing (soft “ka” or “ah” sound indicates the infant is swallowing milk). • Hold the newborn closely, facing the breast, with the newborn’s ear, shoulder, and hip in direct alignment. • Nurse the infant on demand, not on a rigid schedule. Feed every 2 to 3 hours within a 24-hour period for a total of 8 to 12 feedings.

• Alternate the breast you offer first; identify with a safety pin on bra. • Vary your position for each feeding to empty breasts and reduce soreness. • Look for signs that the newborn is getting enough milk: • At least six wet diapers and two to five loose yellow stools daily • Steady weight gain after the first week of age • Pale-yellow urine, not deep yellow or orange • Sleeping well, yet looks alert and healthy when awake • Wake up the newborn if he or she has nursed less than 5 minutes by unwrapping him or her. • Before removing the baby from the breast, break the infant’s suction by inserting a finger. • Burp the infant to release air when changing breasts and at the end of the breast-feeding session. • Avoid supplemental formula feedings unless indicated for a medical reason. Do not take drugs or medications unless approved by the health care provider. • Avoid drinking alcohol or caffeinated drinks because they pass through milk. • Do not smoke while breast-feeding; it increases the risk of sudden infant death syndrome. • Always wash your hands before expressing or handling milk to store. • Wear nursing bras and clothes that are easy to undo. Adapted from Dyson, L., McCormick, F. M., & Renfrew, M. J. (2014). Interventions for promoting the initiation of breastfeeding. Sao Paula Medical Journal, 132(1), 68–72; La Leche League. (2015a). Lactation

support

and

health

care

providers.

Retrieved

from

http://www.llli.org/resources/providers.html?m=0,2; and Walker, M. (2014). Breastfeeding management for the clinician: Using the evidence (3rd ed.). Sudbury, MA: Jones & Bartlett.

Breast Milk Storage and Expression. If the breast-feeding mother becomes separated from the newborn for any reason (e.g., work, travel, or illness), she needs instruction on how to express and store milk safely. Expressing milk can be done manually (hand compression of breast) or by using a breast pump.

Manual or handheld pumps are inexpensive and can be used by mothers who occasionally need an extra bottle if they are going out (Fig. 18.25A). Electric breast pumps are used for mothers who experience a lengthy separation from their infants and need to pump their breasts regularly, e.g., while at the work place (Fig. 18.25B). To ensure the safety of expressed breast milk, instruct the mother as follows: • Wash your hands before expressing milk or handling breast milk. • Find a quiet, clean place to express milk if returned to workplace • Use clean containers to store expressed milk. • Use sealed and chilled milk within 24 hours. • Discard any milk that has been refrigerated for more than 24 hours. • Use any frozen expressed milk within 3 months. • Do not use microwave ovens to warm chilled milk. • Discard any used milk; never refreeze it. • Store milk in quantities to be used for each feeding (2 to 4 oz). • Thaw milk in warm water before using (La Leche League, 2015b).

FIGURE 18.25 A. Hand-held breast pump. B. Electric breast pump. (Part B from Lippincott (2015). Lippincott Nursing Procedures (7th ed.), Philadelphia, PA: Wolters Kluwer).

Common Breast-Feeding Concerns. Breast-feeding women may experience problems such as cracked nipples, engorgement (the painful overfilling of the breasts with milk), or mastitis (inflammation of the breast). Breast-feeding should not be painful for the mother. If she has sore, cracked nipples, the first step is to find the cause. Incorrect positioning or latching-on, removing the infant from the breast without first breaking the suction, or wearing a bra that is too tight can cause cracked or sore nipples. Cracked nipples can increase the risk of mastitis because a break in the skin may allow Staphylococcus aureus or other organisms to enter the body. Sore nipples usually are caused by improper infant attachment, which traumatizes the tissue. The nurse should review techniques for proper positioning and latching-on. It is important to get this correct from the first feed to assist in the prevention of incorrect attachment and associated nipple trauma. Recommend the following to the mother: • Use only warm water, not soap, to clean the nipples to prevent dryness. • Express some milk before feeding to stimulate the milk ejection reflex. • Avoid using breast pads with plastic liners, and change pads when they are wet. • Wear a comfortable bra that is not too tight. • Apply a few drops of breast milk to the nipples after feeding. • Take systemic anti-inflammatory such as ibuprofen for discomfort. • Rotate positions when feeding the infant to promote complete breast emptying. • Leave the nursing bra flaps down after feeding to allow nipples to air-dry. • Inspect the nipples daily for redness or cracks (Walker, 2014). To ease nipple pain and trauma, reinforce appropriate latching-on techniques and remind the woman about the need to break the suction at the breast before removing the newborn from the breast. Additional measures may include applying cold compresses over the area and massaging breast milk onto the nipple after feeding. Engorgement may occur as the milk comes in around day 3 or 4 after birth of the newborn. Explain to the mother that engorgement, though uncomfortable, is self-limited and will resolve as the newborn continues to nurse. The mother should continue to nurse during engorgement to avoid a plugged milk duct, which could lead to mastitis. Provide the following tips for relieving engorgement:

• Take warm to hot showers to encourage milk release. • Express some milk manually before breast-feeding. • Wear a supportive nursing bra 24 hours a day to provide support. • Feed the newborn in a variety of positions—sitting up and then lying down. • Massage the breasts from under the axillary area down toward the nipple. • Increase the frequency of feedings. • Apply warm compresses to the breasts prior to nursing. • Stay relaxed while breast-feeding. • Use a breast pump if nursing or manual expression is not effective. • Remember that this condition is temporary and resolves quickly. Mastitis, or inflammation of the breast, causes flu-like symptoms, chills, fever, and malaise. These symptoms may occur before the development of soreness, aching, swelling, and redness in the breast (usually the upper outer quadrant). This condition usually occurs in just one breast when a milk duct becomes blocked, causing inflammation, or through a cracked or damaged nipple, allowing bacteria to infect a portion of the breast. Treatment consists of rest, warm compresses, antibiotics, breast support, and continued breast-feeding (the infection will not pass into the breast milk). Explain to the mother that it is important to keep the milk flowing in the infected breast, whether it is through nursing or manual expression or with a breast pump. FORMULA-FEEDING Despite the general acknowledgment that breast-feeding is the most desirable means of feeding infants, many mothers choose formula-feeding and need education about this procedure. Formula-fed infants grow more rapidly than breast-fed infants not only in weight but also in length. Formula-feeding requires more than just opening, pouring, and feeding. Parents need information about the types of formula available, preparation and storage of formula, equipment, feeding positions, and the amount to feed their newborn. The mother also needs to know how to prevent lactation (see Chapter 16 for more information). Commercially prepared formulas are regulated by the Food and Drug Administration (FDA), which sets minimum and maximum levels of nutrients. Formulas are manufactured by numerous manufacturers in the United States.

Normal full-term infants usually receive conventional cow milk-based formula, but the health care provider makes this decision. If the infant shows signs of a reaction or lactose intolerance, a switch to another formula type is recommended. The general recommendation is for all infants to receive iron-fortified formula until the age of 1 year. The latest generation of infant formulas includes some fortification with docosahexaenoic acid (DHA) and arachidonic acid (ARA), two natural components of breast milk. Many feel the FDA does not adequately regulate the use of fatty acid additives (DHA and ARA) to infant formula before they are marketed, and there is no systematic assessment after marketing is underway. Researchers are calling for more FDA regulation over additives in infant formulas (Kent, 2014). Commercial formulas come in three forms: powder, concentrate, and easy to feed or ready to use. All are similar in terms of nutritional content but differ in expense. Powdered formula is the least expensive, with concentrated formula the next most expensive. Both must be mixed with water before using. Ready-to-feed formula is the most expensive; it can be opened and poured into a bottle and fed directly to the infant. Parents need information about the equipment needed for formula-feeding. Basic supplies are four to six 4-oz bottles, eight to ten 8-oz bottles, eight to ten nipple units, a bottle brush, and a nipple brush. A key area of instruction is assessing for flow of formula through the nipple and checking for any nipple damage. When the bottle is filled and turned upside down, the flow from the nipple should be approximately one drop per second. If the parents are using bottles with disposable bags, instruct them to make sure they have a tight-fitting nipple to prevent leaks. Frequent observation of the flow rate from the nipple and the condition of the nipple will prevent choking and aspiration associated with too fast a rate of delivery. Ask the parents to fill a bottle with formula and then turn it upside down and observe the rate at which the formula drips from the bottle. If it is too fast (more than one drop per second), then the nipple should be replaced. Correct formula preparation is critical to the newborn’s health and development. Mistakes in dilution may result if the parents do not understand how to prepare the formula or make measurement errors. The safety of the water supply should be considered. If well water is used, parents should sterilize the water by boiling it or should use bottled water. Many health care providers still recommend that all water used in formula preparation be brought to a rolling boil for 1 to 2 minutes and then cooled to room temperature before use.

Opened cans of ready-made or concentrated formula should be covered and refrigerated after being prepared for the day (24 hours). Instruct parents to discard any unused portions after 48 hours.

Take Note! Any formula left in the bottle after feeding should also be discarded, because the infant’s saliva has been mixed with it. To warm refrigerated formula, advise the parents to place the bottle in a pan of hot water or an electric bottle warmer and test the temperature by letting a few drops fall on the inside of the wrist. If it is comfortably warm to the mother, it is the correct temperature. Formula-Feeding Assistance. The process of feeding a newborn formula from a bottle should mirror breast-feeding as closely as possible. Although nutrition is important, so are the emotional and interactive components of feeding. Encourage parents to cuddle their newborn closely and position him or her so that the head is in a comfortable position, not too far back or turned, which makes swallowing difficult (Fig. 18.26). Also urge parents to communicate with their newborn during the feedings by talking and singing to him or her. Although it may seem that bottle-feeding is not a difficult task, many new parents find it awkward. At first glance, holding an infant and a bottle appears simple enough, but both the position of the baby and the angle of the bottle must be correct. Formula-Feeding Positions. Advise mothers to feed their newborns in a relaxed and quiet setting to create a sense of calm for themselves and the baby. Make sure that comfort is a priority for both mother and newborn. The mother can sit in a comfortable chair, using a pillow to support the arm in which she is holding the baby. The mother can cradle the newborn in a semi-upright position, supporting the newborn’s head in the crook of her arm. Holding the newborn close during feeding provides stimulation and helps prevent choking. Holding the newborn’s head raised slightly will help prevent formula from washing backward into the eustachian tubes in the ears, which can lead to an ear infection.

FIGURE 18.26 Father holding his newborn securely while feeding.

Formula-Feeding Education. Parents require teaching about the correct preparation and storage of formula as well as the techniques for feeding; refer to Teaching Guidelines 18.5

Teaching Guidelines 18.5

FORMULA-FEEDING • Wash your hands with soap and water before preparing formula. • Mix the formula and water amounts exactly as the label specifies. • Always hold the newborn and bottle during feedings; never prop the bottle. • Never freeze formula or warm it in the microwave. • Place refrigerated formula in a pan of hot water for a few minutes to warm. • Test the temperature of the formula by shaking a few drops on the wrist. • Hold the bottle like a pencil, keeping it tipped to prevent air from entering. Position the bottle so that the nipple remains filled with milk.

• Burp the infant after every few ounces to allow air swallowed to escape. • Move the nipple around in the infant’s mouth to stimulate sucking. • Always keep a bulb syringe close by to use if choking occurs. • Avoid putting the infant to bed with a bottle to prevent “baby bottle tooth decay.” • Feed the newborn approximately every 3 to 4 hours. • Use an iron-fortified formula for the first year. • Prepare enough formula for the next 24 hours. • Check nipples regularly and discard any that are sticky, cracked, or leaking. • Store unmixed, open liquid formula in the refrigerator for up to 48 hours. • Throw away any formula left in the bottle after each feeding. Proper positioning makes bottle-feeding easier and more enjoyable for both the mother and newborn. As in breast-feeding, frequent burping is key. Advise the parents to hold the bottle so that formula fills the nipple, thus allowing less air to enter. Infants get fussy when they swallow air during feedings and need to be relieved of it every 2 to 3 oz. Emphasize to parents that an electrolyte imbalance can occur in infants who are fed formula that has been incorrectly mixed. Mixing the formula with too little water (i.e., too thickly) can cause hypernatremia because the high concentration of sodium is too much for the baby’s immature kidneys to handle. As a result, sodium is excreted along with water, leading to dehydration. Mixing the formula with too much water in an effort to save money can lead to failure to thrive, diminished nutrition, fluoride overdose, and lack of weight gain (Monahan, 2014). WEANING AND INTRODUCTION OF SOLID FOODS Weaning. Eventually, breast-feeding or formula-feeding comes to an end. Weaning involves the transition from breast to bottle, from breast or bottle to cup, or from liquids to solids. Weaning from breast-feeding to cup has several advantages over weaning to a bottle because it eliminates the step of weaning first to a bottle and then to a cup. Another advantage is that the bottle does not become a security object for the infant. Weaning can be done because the mother is returning to work and cannot keep

breast-feeding, or because the infant is losing interest in breast-feeding and showing signs of independence. There is no “right” time to wean; it depends on the desires of the mother and infant. Weaning represents a significant change in the way the mother and infant interact, and each mother must decide for herself when she and her infant are ready to take that step. Either one can start the weaning process, but usually it occurs between 6 months and 1 year of age. To begin weaning from the breast, instruct mothers to substitute breast-feeding with a cup or a bottle. Often the midday feeding is the easiest feeding to replace. A trainer cup with two handles and a snap-on lid with a spout is appropriate and minimizes spilling. Because weaning is a gradual process, it may take months. Instruct parents to proceed slowly and let the infant’s willingness and interest guide them. Weaning from the bottle to the cup also needs to be timed appropriately for mother and infant. Typically, the night bottle is the last to be given up, with cup drinking substituted throughout the day. Slowly diluting the formula with water over a week can help in this process; the final result is an all-water bottle. To prevent the baby from sucking on the bottle during the night, remove it from the crib after the infant falls asleep. Introduction of Solid Foods. When infants double their birth weight and weigh at least 13 lb, it is time to consider introducing solid foods. Readiness cues include: • Consumption of 32 oz of formula or breast milk daily (estimated) • Ability to sit up with minimal support and turn head away to indicate fullness • Reduction of protrusion reflex so cereal can be propelled to back of throat • Demonstration of interest in food others around them are eating • Ability to open mouth automatically when food approaches it When introducing solid foods, certain principles apply: • New foods should be introduced one at a time and a week apart so that if a problem develops, the responsible item can be identified. • Infants should be allowed to set the pace regarding how much they wish to eat. • New foods should not be introduced more frequently than every 3 to 5 days. • Fruits are added after cereals; then vegetables and meats are introduced; eggs are introduced last.

• A relaxed, unhurried, calm atmosphere for meals is important. • A variety of foods are provided to ensure a balanced diet. • Infants should never be force-fed (Schlenker & Gilbert, 2015). Nurses can promote good feeding practices by actively listening to new mothers, helping them clarify their feelings, and discussing solutions. A warm, sincere manner and tone of voice will put an anxious mother at ease. Giving accurate information, making suggestions, and presenting options will enable the mother to decide what is best for her and her infant. Nurses should be sensitive to the individual, family, and economic and cultural differences among mothers before offering suggestions for feeding practices that may not be appropriate.

Preparing for Discharge Preparing the parents for discharge is an essential task for the nurse. Because of today’s shorter hospital stays, the nurse must identify the major teaching topics that need to be covered. Nurses should assess the parents’ baseline knowledge and learning needs and plan how to meet them. Using the following principles fosters a learner-centered approach: • Make the environment conducive to learning. Encourage the parents to feel comfortable during this stressful time by using support and praise. • Allow the parents to provide input about the content and the process of learning. What do they want and need to learn? • Build the parents’ self-esteem by confirming that their responses to the entire birthing process and aftercare are legitimate, and others have felt the same way. • Ensure that what the parents learn is relevant to their day-to-day home situation. • Encourage responsibility by reinforcing that their emotional and physical responses are within the normal range. • Respect cultural beliefs and practices that are important to the family by taking into account their heritage and health beliefs regarding newborn care. Examples include placing a bellyband over the newborn’s navel (Hispanics and African Americans), delaying naming the newborn (Asian Americans and Haitians), and delaying breast-feeding (Native Americans; they regard colostrum as “bad”) (Bowers, 2015).

While in the hospital, women have ready access to support and hands-on instruction regarding feeding and newborn care. When the new mother is discharged, this close supervision and support by nurses should not end abruptly. Providing the new parents with the phone number of the mother–baby unit will help them through this stressful transitional period. Giving the new family information and offering backup support via the telephone will increase parenting success (see Evidence-Based Practice 18.1). ENSURING FOLLOW-UP CARE Most newborns are scheduled for their first health follow-up appointment within 2 to 4 days after discharge so they can have additional laboratory work done as part of the newborn screening series, especially if they were discharged within 48 hours. After this first visit, the typical schedule of health care visits is as follows: 2 to 4 weeks of age; 2, 4, and 6 months of age for checkups and vaccines; 9 months of age for a checkup; 12 months for a checkup and tuberculosis testing; 15 and 18 months for checkups and vaccines; and 2 years of age for a checkup. These appointments provide an opportunity for parents to ask questions and receive anticipatory guidance as their newborn grows and develops.

Consider This

I have always prided myself on being very organized and in control in most situations, but survival at home after childbirth wasn’t one of them. I left the hospital 24 hours after giving birth to my son because my doctor said I could. The postpartum nurse encouraged me to stay longer, but wanting to be in control and sleeping in my own bed again won out. I thought my baby would be sleeping while I sent out birth announcements to my friends and family— wrong! What happened instead was my son didn’t sleep as I imagined and my nipples became sore after breast-feeding every few hours. I was weary and tired and wanted to sleep, but I couldn’t. Somehow I thought I would be getting a full night’s sleep because I was up throughout the day, but that was a fantasy too. At 2 o’clock in the morning when you are up feeding your baby, you feel you are the only one in the world up at that time and feel very much

alone. My feelings of being organized and in control all the time have changed dramatically since I left the hospital. I have learned to yield to the important needs of my son and derive satisfaction from being able to bring comfort to him and to let go of my control. Thoughts: It is interesting to see how a newborn changed this woman’s need to organize and control her environment. What “tips of survival” could the nurse offer this woman to help in her transition to home with her newborn? How can friends and family help when women arrive home from the hospital with their newborns? In addition to encouraging parents to keep follow-up appointments, advise parents to call their health care provider if they notice signs of illness in their newborn. They should know which over-the-counter medicines should be kept on hand. Review the following warning signs of illness with parents: • Temperature of 101° F (38.3° C) or higher • Forceful, persistent vomiting, not just spitting up • Refusal to take feedings • Two or more green, watery diarrheal stools • Infrequent wet diapers and change in bowel movements from normal pattern • Lethargy or excessive sleepiness • Inconsolable crying and extreme fussiness • Abdominal distention • Difficult or labored breathing

FIGURE 18.27 Recommended childhood immunization schedule.

PROVIDING IMMUNIZATION INFORMATION In the last century, vaccinations have been the most effective medical intervention to reduce mortality and morbidity caused by communicable diseases. It is believed that vaccines save at least two to three million lives annually worldwide (Delany, Rappuoli, & De Gregorio, 2014). Parents also need instructions about immunizations for their newborn. Immunization is the process of rendering an individual immune or of becoming immune to certain communicable diseases (Verklan & Walden, 2015). The purpose of the immune system is to identify unknown (nonself) substances in the body and develop a defense against these invaders. Disease prevention by immunization is a public health priority and is one of the leading health indicators as part of Healthy People 2020. Despite many advances in vaccine delivery, the goal of universal immunization has not been reached (Davidson, 2014). Nurses can help meet this national goal by educating new parents about the importance of disease

prevention through immunizations. Immunity can be provided either passively or actively. Passive immunity is protection transferred via already formed antibodies from one person to another. Passive immunity includes transplacental passage of antibodies from a mother to her newborn, immunity passed through breast milk, and immunity from immunoglobulins. Passive immunity provides limited protection and decreases over a period of weeks or months (Chu & Englund, 2014). Active immunity is protection produced by an individual’s own immune system. It can be obtained by having the actual disease or by receiving a vaccine that produces an immunologic response by that person’s body. Active immunity may be lifelong either way; see Chapter 17. Young infants and children are susceptible to various illnesses because their immune systems are not yet mature. Many of these illnesses can be prevented by following the recommended schedule of childhood immunizations. Figure 18.27 shows the 2015 Childhood Immunization Schedule. Refer to thePoint website for information about how to view the latest CDC immunization schedule. The schedule for immunizations should be reviewed with parents, stressing the importance of continued follow-up health care to preserve their infant’s health. The newborn’s first immunization (hepatitis B) is received in the hospital soon after birth. The first dose can also be given by age 2 months if the mother is HbsAg negative. If the mother is HbsAg positive, then the newborn should receive hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours of birth (Cunningham et al., 2014). Education for the parents should include the risks and benefits for each vaccine and possible adverse effects. Federal law requires a consent form to be signed before administering a vaccine. Parents have the right to refuse immunizations based on their religious beliefs and can sign a waiver noting their decision. When consent has been received, the nurse administering the vaccine must document the date and time it was given, name and manufacturer, lot number and expiration date of the vaccine given, site and route of administration, and the name and title of the nurse who administered the vaccine. Despite overwhelming evidence of vaccine safety, suspicion and misconception continues in small groups of hesitant or resistant parents/partners/significant others, often leading to outbreaks of vaccine-preventable infections. On the front lines of vaccinations, nurses can improve vaccination rates by developing trust with parents/partners/significant others and arming them with information based on sound evidence.

KEY CONCEPTS The period of transition from intrauterine to extrauterine life occurs during the first several hours after birth. It is a time of stabilization for the newborn’s temperature, respiration, and cardiovascular dynamics. The newborn’s bowel is sterile at birth. It usually takes about a week for the newborn to produce vitamin K in sufficient quantities to prevent VKDB. It is recommended that all newborns in the United States receive an installation of a prophylactic agent (erythromycin or tetracycline ophthalmic ointment) in their eyes within an hour or two of being born. Nursing measures to maintain newborns’ body temperature include drying them immediately after birth to prevent heat loss through evaporation, wrapping them in prewarmed blankets, putting a hat on their head, and placing them under a temperature-controlled radiant warmer. The specific components of a typical newborn examination include a general survey of skin color, posture, state of alertness, head size, overall behavioral state, respiratory status, gender, and any obvious congenital anomalies. Gestational age assessment is pertinent because it allows the nurse to plot growth parameters and to anticipate potential problems related to prematurity/postmaturity and growth abnormalities such as SGA/LGA. After the newborn has passed the transitional period and stabilized, the nurse needs to complete ongoing assessments, vital signs, weight and measurements, cord care, hygiene measures, newborn screening tests, and various other tasks until the newborn is discharged home from the birthing unit. Important topics about which to educate parents include environmental safety, newborn characteristics, feeding and bathing, circumcision and cord care, sleep and elimination patterns of newborns, safe infant car seats, holding/positioning, and follow-up care. Newborn screening tests consist of hearing and certain genetic and inborn errors of metabolism tests required in most states for newborns before discharge from the birth facility. The AAP and the American Dietetic Association recommend breast-feeding exclusively for the first 6 months of life and that it continue along with other food at least until the first birthday.

Parents who choose not to breast-feed need to know what types of formula are available, preparation and storage of formula, equipment, feeding positions, and how much to feed their infant. Common problems associated with the newborn include transient tachypnea, physiologic jaundice, and hypoglycemia. Transient tachypnea of the newborn appears soon after birth; is accompanied by retractions, expiratory grunting, or cyanosis; and is relieved by low-dose oxygen. Physiologic jaundice is a very common condition in newborns, with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life. Newborns undergoing phototherapy in the treatment of jaundice require close monitoring of their body temperature and fluid and electrolyte balance; observation of skin integrity; eye protection; and parental participation in their care. The newborn with hypoglycemia requires close monitoring for signs and symptoms of hypoglycemia if present. In addition, newborns at high risk need to be identified based on their perinatal history, physical examination, body measurements, and gestational age. The schedule for immunizations should be reviewed with parents, stressing the importance of continual follow-up health care to preserve their infant’s health.

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Nikolopoulos, T. P. (2015). Neonatal hearing screening: What we have achieved and what needs to be improved. International Journal of Pediatric Otorhinolaryngology, 79(5), 635–637. Otsuka, Y. (2014). Face recognition in infants: A review of behavioral and near-infrared spectroscopic studies. Japanese Psychological Research, 56(1), 76–90. Pfister, K. M., & Ramel, S. E. (2014). Linear growth and neurodevelopmental outcomes. Clinics in Perinatology, 41(2), 309–321. Plavskii, V. Y., Tret’yakova, A. I., & Mostovnikova, G. R. (2014). Phototherapeutic systems for the treatment of hyperbilirubinemia of newborns. Journal of Optical Technology, 81(6), 341–348. Rüdiger, M., & Konstantelos, D. (2015). Apgar score and risk of cause-specific infant mortality. The Lancet, 385(9967), 505–506. Saugstad, O. D. (2015). Delivery room management of term and preterm newly born infants. Neonatology, 107(4), 365–371. Schlenker, E., & Gilbert, J. A. (2015). William’s essentials of nutrition and diet therapy (11th ed.). St. Louis, MO: Elsevier. Sheth, R. D., Ranalli, N., & Aldana, P. (2014). Pediatric craniosynostosis. eMedicine, Retrieved from http://emedicine.medscape.com/article/1175957-overview Silverberg, N. B. (2015). Normal color variations in children of color. In Pediatric skin of color (pp. 63–68). New York, NY: Springer. Sinkey, R. G., Eschenbacher, M. A., Walsh, P. M., Doerger, R. G., Lambers, D. S., Sibai, B. M., et al. (2015). The GoMo study: A randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision. American Journal of Obstetrics and Gynecology, 212(5), 664--e1. Skidmore-Roth, L. (2015). Mosby’s 2015 nursing drug reference (28th ed.). St. Louis, MO: Elsevier. Springer, S. C., & Glasser, J. G. (2015). Bowel obstruction in the newborn. eMedicine. Retrieved from http://emedicine.medscape.com/article/980360-overview Stanley, C. A., Rozance, P. J., Thornton, P. S., De Leon, D. D., Harris, D., Haymond, M. W., et al. (2015). Re-evaluating “transitional neonatal hypoglycemia”: mechanism and implications for management. The Journal of Pediatrics, 166(6), 1520––1525. Tamai, J., & McCarthy, J. J. (2015). Developmental dysplasia of the hip. eMedicine. Retrieved from http://emedicine.medscape.com/article/1248135-overview Tawia, S., & McGuire, L. (2014). Early weight loss and weight gain in healthy, full-term, exclusivelybreastfed infants. Breastfeeding Review, 22(1), 31–42 Thornton, P. S., Stanley, C. A., De Leon, D. D., Harris, D., Haymond, M. W., Hussain, K., et al. (2015). Recommendations from the Pediatric Endocrine Society for evaluation and management of persistent hypoglycemia in neonates, infants, and children. The Journal of Pediatrics, 167(2), 238–245. Tobian, A. A., Kacker, S., & Quinn, T. C. (2014). Male circumcision: a globally relevant but under-utilized method for the prevention of HIV and other sexually transmitted infections. Annual Review of Medicine,

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CHAPTER WORKSHEET MULTIPLE CHOICE QUESTIONS 1. At birth, a newborn’s assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn’s Apgar score as: a. 5 points b. 6 points c. 7 points d. 8 points 2. The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? a. Increase surfactant levels b. Stabilize the newborn’s temperature c. Destroy Rh-negative antibodies d. Oxidize bilirubin on the skin 3. The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to promote:

a. Conjugation of bilirubin b. Blood clotting c. Foreman ovale closure d. Digestion of complex proteins 4. A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? a. Gonorrhea and chlamydia b. Thrush and enterobacter c. Staphylococcus and syphilis d. Hepatitis B and herpes 5. The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of: a. Respiratory distress syndrome b. Bottle mouth syndrome c. Sudden infant death syndrome d. GI regurgitation syndrome 6. Which one of the following immunizations is most commonly received by newborns before hospital discharge? a. Pneumococcus b. Varicella c. Hepatitis A d. Hepatitis B 7. Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. Hypothyroidism b. Cystic fibrosis c. Phenylketonuria d. Sickle cell disease

8. Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. Two soft spots palpated between the cranial bones b. A spongy area of edema outlined on the head c. Head circumference 32 cm, chest 34 cm d. Asymmetry of the head with overriding bones 9. Which of the following findings in a newborn would be considered normal? a. Passage of meconium within the first 24 hours b. Respiratory rate of 80 breaths/minute c. Yellow skin tones at 10 hours after birth d. Bleeding from the umbilicus area

CRITICAL THINKING EXERCISE 1. An African American mother who delivered her first baby, and is on the mother–baby unit, calls the nursery nurse into her room and expresses concern about how her daughter looks. The mother tells the nurse that her baby’s head looks like a “banana” and is mushy to the touch, and she has “white spots” all over her nose. In addition, there appear to be “big bluish bruises” all over her baby’s buttocks. She wants to know what is wrong with her baby and whether these problems will go away. a. How should the nurse respond to this mother’s questions? b. What additional newborn instruction might be appropriate at this time? c. What reassurance can be given to this new mother regarding her daughter’s appearance? 2. At approximately 12:30 am on a Friday, a woman enters a hospital through a busy emergency department. She is wearing a white uniform and a lab coat with a stethoscope around her neck. She identifies herself as a new nurse coming back to check on something she had left on the unit on an earlier shift. She enters a postpartum client’s room containing the mother’s newborn, pushes the open crib down a hallway, and escapes through an exit. The security cameras aren’t working. The infant isn’t discovered missing until the 2 am check by the nurse.

a. What impact does an infant abduction have on the family and the hospital? b. What security measure was the weak link in the chain of security? c. What can hospitals do to prevent infant abduction?

STUDY ACTIVITIES 1. Obtain a set of vital signs (temperature, pulse, and respiration) of a newborn on admission to the nursery. Repeat this procedure and compare changes in the values several hours later. Discuss what changes in the vital signs you would expect during this transitional period. The discussion of newborn changes noticed will vary from student to student, depending on the interview information obtained from the new mother. 2. Interview a new mother on the postpartum unit on her second day about the changes she has noticed in her newborn’s appearance and behavior within the past 24 hours. Discuss your interview findings at postconference. This discussion will vary depending on questions asked during the bath demonstration as well as each individual mother’s response to it. 3. Demonstrate a newborn bath to a new mother in her room, using the principle of bathing from the cleanest to the dirtiest body part. Discuss the questions asked by the mother and her reaction to the demonstration in postconference. 4. Go to the La Leche League web site (refer to thePoint website). Review the information it provides on breast-feeding. How helpful would it be to a new mother? The La Leche League website is filled with helpful information with pictures to assist new mothers with breast-feeding. Each student will have his or her own opinion about how helpful the website is and what educational level it addresses. 5. Debate the risks and benefits of neonatal circumcision within your nursing group at postconference. Did either side present a stronger position? What is your opinion, and why? The risks of neonatal circumcision include hemorrhage, infection,

adhesions, dehiscence, urethral fistula, meatal stenosis, and pain. The benefits of neonatal circumcision include prevention of penile cancer, decreased incidence of UTIs and STIs, and preservation of male body consistent with father and peers where the procedure is common. Students will express their own opinions about their thoughts based on their value systems and cultural backgrounds.

BRINGING IT ALL TOGETHER: CASE STUDY Two days after having a difficult birth of her first child at 37 weeks’ gestation, 25-year-old Molly and her partner took their son home from the hospital. That evening while she was breast-feeding him, Molly noticed that the whites of her son’s eyes seemed slightly yellow, a condition that worsened noticeably by the next day. Molly called the Healthy Start Home Health nurse and requested a visit to evaluate her newborn.

ASSESSMENT Upon examining the 3-day-old newborn, the nurse noted that there were a few areas of bruising on the newborn’s head and a yellow hue on the infant’s skin when she pressed on boney prominent areas. When questioning the mother about her breast-feeding, the mother stated that her son didn’t seem all that interested at times, so she let him sleep instead. Go to

to find questions to consider about this case.

unit seven Childbearing at Risk

19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

KEY TERMS abortion abruptio placentae eclampsia ectopic pregnancy gestational hypertension gestational trophoblastic disease (GTD) high-risk pregnancy polyhydramnios hyperemesis gravidarum

multiple gestation oligohydramnios placenta accreta placenta previa preeclampsia premature rupture of membranes (PROM) preterm premature rupture of membranes (PPROM)

Learning Objectives Upon completion of the chapter, you will be able to: 1. Compare and contrast a normal pregnancy to a high risk one. Determine the common factors that might place a pregnancy at high risk. 2. Detect the causes of vaginal bleeding during early and late pregnancy. 3. Outline nursing assessment and management for the pregnant woman experiencing vaginal bleeding. 4. Develop a plan of care for the woman experiencing preeclampsia, eclampsia, and HELLP syndrome. 5. Examine the pathophysiology of hydramnios and subsequent management. 6. Evaluate factors in a woman’s prenatal history that place her at risk for premature rupture of membranes (PROMs). 7. Formulate a teaching plan for maintaining the health of pregnant women experiencing a high-risk pregnancy. Helen, a 35-year-old G5 P4, presents to the labor and birth suite with severe abdominal pain. She reports that the pain began suddenly about an hour ago while she was resting. She has had two prior cesarean births and thus far has had an uneventful past 32 weeks. Helen appears distressed and is moaning. What additional assessments do you need to do to care for Helen? What might be your immediate nursing action?

Words of Wisdom Detours and bumps along the road of life can be managed, but many cannot be

entirely cured.

INTRODUCTION Most people view pregnancy as a natural process with a positive outcome—the birth of a healthy newborn. Unfortunately, conditions can occur that may result in negative outcomes for the fetus, mother, or both. A high-risk pregnancy is one in which a condition exists that jeopardizes the health of the mother, her fetus, or both. The condition may result from the pregnancy, or it may be a condition that was present before the woman became pregnant. Approximately, one in four pregnant women is considered to be at high risk or diagnosed with complications (Nagtalon-Ramos, 2014). Women who are considered to be at high risk have a higher morbidity and mortality compared with mothers in the general population. The risk status of a woman and her fetus can change during the pregnancy, with a number of problems occurring during labor, birth, or afterward, even in women without any known previous antepartal risk. Examples of high-risk conditions include gestational diabetes and ectopic pregnancy. Many obstetric complications and conditions are life-threatening emergencies with high morbidity and mortality rates. It is essential that these be identified early to ensure the best possible outcome for the mother and infant. These conditions are specifically addressed in Healthy People 2020 (U.S. Department of Health and Human Services, 2010). Early identification of the woman at risk is essential to ensure that appropriate interventions are instituted promptly, increasing the opportunity to change the course of events and provide a positive outcome. The term risk may mean different things to different groups. For example, health care providers may focus on the disease processes and treatments to prevent complications. Nurses may focus on nursing care and on the psychosocial impact on the woman and her family. Insurance companies may concentrate on the economic issues related to the high-risk status. The woman’s attention may be focused on her own needs and those of her family. Together, working as a collaborative team, the ultimate goal of care is to ensure the best possible outcome for the woman, her fetus, and her family.

HEALTHY PEOPLE 2020 • 19.1

Risk assessment begins at the first antepartal visit and continues with each subsequent visit because factors may be identified in later visits that were not apparent during earlier visits. For example, as the nurse and client develop a trusting relationship, previously unidentified or unsuspected factors (such as drug abuse or intimate partner violence) may be revealed. Through education and support, the nurse can encourage the client to inform her health care provider of these concerns, and necessary interventions or referrals can be made. Various factors must be considered when determining a woman’s risk for adverse pregnancy outcomes, and a comprehensive approach to high-risk pregnancy is needed. For example, prenatal stress and distress have been shown to have significant consequences for the mother, child, and family. Pregnancyspecific stress such as depression, anxiety, and perceived stress may increase the risk for adverse birth outcomes and is associated with preterm births (Staneva et al., 2015). Risks are grouped into broad categories based on threats to health and pregnancy outcome. Current categories of risk are biophysical, psychosocial, sociodemographic, and environmental (Box 19.1) (Cunningham et al., 2014). This chapter describes the major conditions directly related to pregnancy that can complicate a pregnancy, possibly affecting maternal and fetal outcomes. These include bleeding during pregnancy (spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease, cervical insufficiency, placenta

previa, abruptio placentae, and placenta accreta), hyperemesis gravidarum, gestational hypertension, HELLP syndrome, gestational diabetes, blood incompatibility, amniotic fluid imbalances (polyhydramnios and oligohydramnios), multiple gestation, and premature rupture of membranes. Chapter 20 addresses preexisting conditions that can complicate a woman’s pregnancy as well as populations that are considered to be at high risk.

BLEEDING DURING PREGNANCY Bleeding at any time during pregnancy is potentially life threatening. Every minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric hemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are strategic to reducing maternal morbidity and mortality (World Health Organization [WHO], 2015). Management of obstetric hemorrhage involves early recognition, assessment, and resuscitation. Various methods are available to try to stop the bleeding, ranging from pharmacologic methods to aid uterine contraction (e.g., oxytocin, ergometrine, and prostaglandins) to surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures, or arterial ligation). Bleeding can occur early or late in the pregnancy and may result from numerous conditions. Bleeding is experienced by approximately 20% of women during the first trimester of pregnancy (Knez, Day, & Jurkovic, 2014). Conditions commonly associated with early bleeding (first half of pregnancy) include spontaneous abortion, uterine fibroids, ectopic pregnancy, gestational trophoblastic disease, and cervical insufficiency. Conditions associated with late bleeding include placenta previa, abruptio placentae, and placenta accreta, which usually occur after the 20th week of gestation.

BOX 19.1 FACTORS PLACING A WOMAN AT RISK DURING PREGNANCY

Biophysical Factors • Genetic conditions • Chromosomal abnormalities • Multiple pregnancy • Defective genes • Inherited disorders • ABO incompatibility • Large fetal size • Medical and obstetric conditions • Preterm labor and birth • Cardiovascular disease • Chronic hypertension • Cervical insufficiency • Placental abnormalities • Infection • Diabetes • Maternal collagen diseases • Thyroid disease • Asthma • Post-term pregnancy • Hemoglobinopathies • Nutritional status • Inadequate dietary intake • Food fads • Excessive food intake • Under- or overweight status • Hematocrit value less than 33% • Eating disorder

Psychosocial Factors • Smoking • Caffeine • Alcohol and substance abuse • Maternal obesity • Inadequate support system • Situational crisis • History of violence • Emotional distress • Unsafe cultural practices

Sociodemographic Factors • Poverty status • Lack of prenatal care • Age younger than 15 years or older than 35 years • Parity—All first pregnancies and more than five pregnancies • Marital status—Increased risk for unmarried women • Accessibility to health care • Ethnicity—Increased risk in non-White women

Environmental Factors • Infections • Radiation • Pesticides • Illicit drugs • Industrial pollutants • Second-hand cigarette smoke • Personal stress Adapted from Martin, R. J., Fanaroff, A. A., & Walsh, M. C. (2014). Fanaroff & Martin’s neonatalperinatal medicine (10th ed.). Philadelphia, PA: Elsevier Health Sciences; Foley, M., Strong, T. M., & Garite, T. (2014). Obstetric intensive care manual (4th ed.). New York, NY: McGraw-Hill Publishers; and Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Sheffield, J. S. (2014). Williams’ obstetrics (24th ed.). New York, NY: McGraw-Hill Education.

Spontaneous Abortion Abortion is considered not only a major reproductive health matter, but also a health risk factor for women’s well-being. Spontaneous abortion is the most common complication of early pregnancy (Tulandi & Al-Fozan, 2014). An abortion is the loss of an early pregnancy, usually before week 20 of gestation. Abortion can be spontaneous or induced. A spontaneous abortion refers to the loss of a fetus resulting from natural causes, that is, not elective or therapeutically induced by a procedure. A stillbirth is the loss of a fetus after the 20th week of development, whereas a miscarriage refers to a loss before the 20th week. Nonmedical people often use the term miscarriage to denote an abortion that has occurred spontaneously. A miscarriage can occur during early pregnancy, and many women who miscarry may not even be aware that they are pregnant. About 80% of spontaneous abortions occur within the first trimester. The terms stillbirth and miscarriage can sometimes be confusing. Both refer to the loss of an early pregnancy; however, stillbirth occurs later in pregnancy. Some stillbirths can occur right up to the time of labor and delivery. Stillbirths are much less common than miscarriages, occurring in only 1 out of every 160 pregnancies (March of Dimes, 2015a). The overall rate for spontaneous abortion in the United States is reported to be 15% to 20% of recognized pregnancies in the United States. However, with the development of highly sensitive assays for human chorionic gonadotropin (hCG) levels that detect pregnancies prior to the expected next menses, the incidence of pregnancy loss increases significantly—to about 60% to 70% (King et al., 2015). The frequency of spontaneous abortion increases further with maternal age.

Pathophysiology The causes of spontaneous abortion are varied and often unknown. The most common cause for first-trimester abortions is fetal genetic abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely causes in the first trimester and maternal disease is more likely in the second trimester. Those occurring during the second trimester are more likely related to maternal conditions, such as cervical insufficiency, congenital, or acquired anomaly of the uterine cavity (uterine septum or fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, use of crack cocaine, inherited and acquired thrombophilias,

lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis (Jones & Lopez, 2014). Women experiencing a first-trimester abortion at home without a dilation and curettage (D&C) to resolve it require frequent monitoring of hCG levels to validate that all the conceptus tissues have been expelled. Women going through a second-trimester abortion are admitted to the hospital to have an augmented labor and delivery. Nursing care would focus on care of the laboring women with tremendous attention paid to providing emotional support to the woman and her family.

Nursing Assessment When a pregnant woman calls and reports vaginal bleeding, she must be seen as soon as possible by a health care professional to ascertain the etiology. Varying degrees of vaginal bleeding, low back pain, abdominal cramping, and passage of products of conception tissue may be reported. Ask the woman about the color of the vaginal bleeding (bright red is significant) and the amount—for example, question her about the frequency with which she is changing her peripads (saturation of one peripad hourly is significant) and the passage of any clots or tissue. Instruct her to save any tissue or clots passed and bring them with her to the health care facility. Also, obtain a description of any other signs and symptoms the woman may be experiencing, along with a description of their severity and duration. It is important to remain calm and listen to the woman’s description. When the woman arrives at the health care facility, assess her vital signs and observe the amount, color, and characteristics of the bleeding. Ask her to rate her current pain level, using an appropriate pain assessment tool. Also, evaluate the amount and intensity of the woman’s abdominal cramping or contractions, and assess the woman’s level of understanding about what is happening to her. A thorough assessment helps in determining the type of spontaneous abortion, such as threatened abortion, inevitable abortion, incomplete abortion, complete abortion, missed abortion, and habitual abortion, that the woman may be experiencing (Table 19.1).

Nursing Management Nursing management of the woman with a spontaneous abortion focuses on

providing continued monitoring and psychological support, for the family is experiencing acute loss and grief. An important component of this support is reassuring the woman that spontaneous abortions usually result from an abnormality and that her actions did not cause the abortion. PROVIDING CONTINUED MONITORING Continued monitoring and ongoing assessments are essential for the woman experiencing a spontaneous abortion. Monitor the amount of vaginal bleeding through pad counts and observe for passage of products of conception tissue. Assess the woman’s pain and provide appropriate pain management to address the cramping discomfort. Assist in preparing the woman for procedures and treatments such as surgery to evacuate the uterus or medications such as misoprostol or PGE2. If the woman is Rh negative and not sensitized, expect to administer RhoGAM within 72 hours after the abortion is complete. Drug Guide 19.1 gives more information about these medications. PROVIDING SUPPORT A woman’s emotional reaction may vary depending on her desire for this pregnancy and her available support network. Provide both physical and emotional support. In addition, prepare the woman and her family for the assessment process and answer their questions. Explaining some of the causes of spontaneous abortions can help the woman to understand what is happening and may allay her fears and guilt that she did something to cause the pregnancy loss. Most women experience an acute sense of loss and go through a grieving process with a spontaneous abortion. Providing sensitive listening, counseling, and anticipatory guidance to the woman and her family will allow them to verbalize their feelings and ask questions about future pregnancies. The grieving period may last as long as two years after a pregnancy loss, with each person grieving in his or her own way. Encourage friends and family to be supportive but give the couple space and time to work through their loss. Referral to a community support group for parents who have experienced a miscarriage can be very helpful during this grief process. TABLE 19.1 CATEGORIES OF ABORTION

Ectopic Pregnancy An ectopic pregnancy is any pregnancy in which the fertilized ovum implants outside the uterine cavity. The term ectopic is derived from the Greek word ektopos, meaning “out of place,” and refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, and the abdominal cavity. This abnormally implanted embryo grows and draws its blood supply from the site of abnormal implantation. As the embryo enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death.

DRUG GUIDE 19.1 MEDICATIONS RELATED TO ABORTIONS

Ectopic pregnancies occur in 1 in every 50 pregnancies in the United States or roughly 2% of all pregnancies are diagnosed as ectopic; this rate has increased dramatically during the past 30 years (March of Dimes, 2015b). It is a major health concern for women of reproductive age and is the primary cause of death during the first trimester of pregnancy in the United States (Szypulski, 2015). The discovery of ectopic pregnancies prior to rupture has increased dramatically in the past few decades as a result of improved diagnostic techniques such as the development of sensitive and specific radioimmunoassays for hCG, highresolution ultrasonography, and the widespread availability of laparoscopy (Desai et al., 2014). With an ectopic pregnancy, rupture and hemorrhage may occur due to the growth of the embryo. A ruptured ectopic pregnancy is a medical emergency; therefore prediction of any tubal rupture before its occurrence is extremely

important. It is a potentially life-threatening condition and involves pregnancy loss. Even in the United States, women can and do still die from ectopic pregnancy, although early diagnosis has helped prevent that.

Pathophysiology Normally, the fertilized ovum implants in the uterus. In ectopic pregnancy, the journey along the fallopian tube is arrested or altered in some way. With an ectopic pregnancy, the ovum implants outside the uterus. The most common site for implantation is the fallopian tubes, but some ova may implant in the ovary, the intestine, the cervix, or the abdominal cavity (Fig. 19.1) (Sepilian & Wood, 2015). None of these anatomic sites can accommodate placental attachment or a growing embryo.

FIGURE 19.1 Possible sites for implantation with an ectopic pregnancy.

Risk Factors Ectopic pregnancies usually result from conditions that obstruct or slow the passage of the fertilized ovum through the fallopian tube to the uterus. This may be a physical blockage in the tube, or failure of the tubal epithelium to move the zygote (the cell formed after the egg is fertilized) down the tube into the uterus. In the general population, most cases are the result of tubal scarring secondary to pelvic inflammatory disease (PID). Organisms such as Neisseria gonorrhea and

Chlamydia trachomatis preferentially attack the fallopian tubes, producing silent infections. A recent study reported a twofold increased risk for ectopic pregnancy in women with a history of a chlamydia infection, secondary to tubal damage (Randall & LaMontagne, 2015). Other associated risk factors for ectopic pregnancy include previous tubal surgery, infertility, PID, previous pregnancy loss (induced or spontaneous, use of an intrauterine contraceptive system, previous ectopic pregnancy, uterine fibroids, sterilization, smoking (which alters tubal motility), history of multiple sexual partners, use of progestin-only oral contraceptives, douching, and exposure to diethylstilbestrol (DES) (Ardehali & Casikar, 2015).

Therapeutic Management The diagnosis of ectopic pregnancy can be challenging because many women are asymptomatic before tubal rupture. The classic clinical triad of ectopic pregnancy includes abdominal pain, amenorrhea, and vaginal bleeding. Unfortunately, only about half of women present with all three symptoms. Diagnostic procedures used for a suspected ectopic pregnancy include a urine pregnancy test to confirm the pregnancy, beta-hCG concentrations to exclude a false-negative urine test, and a transvaginal ultrasound to visualize the misplaced pregnancy (Bourne, 2015). Historically, the treatment of ectopic pregnancy was limited to surgery. The therapeutic management of ectopic pregnancy depends on whether the tube is intact or has ruptured, creating a medical emergency. In the event of a surgical intervention, preservation of the affected fallopian tube is attempted (King et al., 2015). MEDICAL INTERVENTION With early diagnosis, most women with ectopic pregnancy could be treated with methotrexate. The overall success rate of medical treatment in properly selected women is nearly 90%. To be eligible for medical therapy, the client must be hemodynamically stable, with no signs of active bleeding in the peritoneal cavity, low beta-hCG levels (140/90) without proteinuria after 20 weeks’ gestation resolving by 12 weeks’ postpartum (Magowan, Owen, & Thomson, 2014). Previously, gestational hypertension was known as pregnancy-induced hypertension or toxemia of pregnancy, but these terms are no longer used. Gestational hypertension is defined as systolic blood pressure > 140 mm Hg and/or diastolic > 90 mm Hg on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation, in women known to be normotensive prior to this time and prior to pregnancy (King et al., 2015). Gestational hypertension can be differentiated from chronic hypertension, which appears before the 20th week of gestation; or hypertension before the current pregnancy, which continues after the woman gives birth. A recent study found that progesterone supplementation during the first trimester significantly reduced the incidence of gestational hypertension and fetal distress in primigravida women. This supplementation might be a future therapy with addition studies to validate it (Zainul et al., 2014).

Preeclampsia and Eclampsia Normal physiologic adaptations to pregnancy are altered in the woman who develops preeclampsia. Preeclampsia can be described as a multisystem, vasopressive disorder that targets the cardiovascular, hepatic, renal, and central nervous systems (CNSs). Preeclampsia can be classified as mild or severe with a potential progression to eclampsia. Each is associated with specific criteria. Comparison Chart 19.2 highlights these classifications.

Pathophysiology Preeclampsia remains an enigma. The condition can be devastating to both the mother and fetus, yet the etiology still remains a mystery to medical science despite decades of research. Many theories exist, but none has truly explained the widespread pathologic changes that result in pulmonary edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes (Cunningham et al., 2014). Despite the results of several research studies, the use of aspirin or supplementation with calcium, magnesium, zinc, or antioxidant therapy (vitamin C and E), salt restriction, diuretic therapy, or fish oils has not proved to prevent this destructive condition. Preeclampsia is a two-stage event; .the underlying mechanisms involved are vasospasm and hypoperfusion. In the first stage, the key feature is widespread vasospasm. In addition, endothelial injury occurs, leading to platelet adherence, fibrin deposition, and the presence of schistocytes (fragment of an erythrocyte). The second stage of preeclampsia is the woman’s response to abnormal placentation, when symptoms appear, i.e., hypertension, proteinuria, and edema due to hypoperfusion. The first stage of generalized vasospasm results in elevation of blood pressure and reduced blood flow to the brain, liver, kidneys, placenta, and lungs. Decreased liver perfusion leads to impaired liver function and subcapsular hemorrhage. This is demonstrated by epigastric pain and elevated liver enzymes in the maternal serum. Decreased brain perfusion leads to small cerebral hemorrhages and symptoms of arterial vasospasm such as headaches, visual disturbances, blurred vision, and hyperactive deep tendon reflexes (DTRs). A thromboxane/prostacyclin imbalance leads to increased thromboxane (potent vasoconstrictor and stimulator of platelet aggregation) and decreased

prostacyclin (potent vasodilator and inhibitor of platelet aggregation), which contribute to the hypertensive state. Decreased kidney perfusion reduces the glomerular filtration rate, resulting in decreased urine output and increased serum levels of sodium, BUN, uric acid, and creatinine, further increasing extracellular fluid and edema. Increased capillary permeability in the kidneys allows albumin to escape, which reduces plasma colloid osmotic pressure and moves more fluid into extracellular spaces; this leads to pulmonary edema and generalized edema. Poor placental perfusion resulting from prolonged vasoconstriction helps to contribute to intrauterine growth restriction, premature separation of the placenta (abruptio placentae), persistent fetal hypoxia, and acidosis. In addition, hemoconcentration (resulting from decreased intravascular volume) causes increased blood viscosity and elevated hematocrit (ACOG, 2014c).

COMPARISON CHART 19.2 PREECLAMPSIA VERSUS ECLAMPSIA

Therapeutic Management Management of the woman with preeclampsia varies depending on the severity

of her condition and its effects on the fetus. Typically the woman is managed conservatively if she is experiencing mild symptoms. However, if the condition progresses, management becomes more aggressive. The “cure” for preeclampsia/eclampsia is always delivery of the placenta. The resolution following expulsion of the placenta supports theories related to the placental influence on the disease (Dekker, 2014). According to recent studies, prevention of preeclampsia should be considered with daily low-dose aspirin from 12 weeks’ gestation and onward to women identified at high risk for it. While women with chronic hypertension or a personal history of preeclampsia should receive aspirin during pregnancy, further research should be ongoing to predict preeclampsia in low risk women (Bujold, 2015). MANAGEMENT FOR MILD PREECLAMPSIA Conservative strategies for mild preeclampsia are used if the woman exhibits no signs of renal or hepatic dysfunction or coagulopathy. A woman with mild elevations in blood pressure may be placed on bed rest at home. She is encouraged to rest as much as possible in the lateral recumbent position to improve uteroplacental blood flow, reduce her blood pressure, and promote diuresis. In addition, antepartal visits and diagnostic testing—such as CBC, clotting studies, liver enzymes, and platelet levels—increase in frequency. The woman will be asked to monitor her blood pressure daily (every 4 to 6 hours while awake) and report any increased readings; she will also measure the amount of protein found in urine using a dipstick and will weigh herself for any weight gain. She also should take daily fetal movement counts, and if there is any decrease in movement, she needs to be evaluated by her health care provider that day. A balanced, nutritional diet with no sodium restriction is advised. In addition, she is encouraged to drink six to eight 8-oz glasses of water daily. If home management fails to reduce the blood pressure, admission to the hospital is warranted and the treatment strategy is individualized based on the severity of the condition and the gestational age at the time of diagnosis. During the hospitalization, the woman with mild preeclampsia is monitored closely for signs and symptoms of severe preeclampsia or impending eclampsia (e.g., persistent headache, hyperreflexia). Blood pressure measurements are frequently recorded along with daily weights to detect excessive weight gain resulting from edema. Fetal surveillance is instituted in the form of daily fetal movement counts, nonstress testing, and serial ultrasounds to evaluate fetal growth and amniotic fluid volume to confirm fetal well-being. Expectant

management (watchful waiting) usually continues until the pregnancy reaches term, fetal lung maturity is documented, or complications develop that warrant immediate birth. Women with mild preeclampsia are at greatest risk for postpartum hypertension (King et al., 2015). Prevention of disease progression is the focus of treatment during labor. Blood pressure is monitored frequently and a quiet environment is important to minimize the risk of stimulation and to promote rest. Intravenous magnesium sulfate is infused to prevent any seizure activity, along with antihypertensives if blood pressure values begin to rise. Calcium gluconate is kept at the bedside in case the magnesium level becomes toxic. Continued close monitoring of neurologic status is warranted to detect any signs or symptoms of hypoxemia, impending seizure activity, or increased intracranial pressure. An indwelling urinary (Foley) catheter usually is inserted to allow for accurate measurement of urine output. MANAGEMENT FOR SEVERE PREECLAMPSIA Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 5 g in 24 hours, oliguria of less than 400 mL in 24 hours, cerebral and visual symptoms, and rapid weight gain. This clinical picture signals severe preeclampsia, and immediate hospitalization is needed. Treatment is highly individualized and based on disease severity and fetal age. Birth of the infant is the only cure, because preeclampsia depends on the presence of trophoblastic tissue. Therefore, the exact age of the fetus is assessed to determine viability. Severe preeclampsia is treated aggressively because hypertension poses a serious threat to mother and fetus. The goal of care is to stabilize the mother– fetus dyad and prepare for birth. Therapy focuses on controlling hypertension, preventing seizures, preventing long-term morbidity, and preventing maternal, fetal, or newborn death (Foo et al., 2015). Intense maternal and fetal surveillance starts when the mother enters the hospital and continues throughout her stay. The woman in labor with severe preeclampsia typically receives oxytocin to stimulate uterine contractions and magnesium sulfate to prevent seizure activity. Oxytocin and magnesium sulfate can be given simultaneously via infusion pumps to ensure both are administered at the prescribed rate. Magnesium sulfate is given intravenously via an infusion pump. A loading dose of 4 to 6 g is given over 5 minutes. Then, a maintenance dose of 2 g/hr is given.

The client is evaluated closely for magnesium toxicity. If at all possible, a vaginal delivery is preferable to a cesarean birth for better maternal outcomes and less risk associated with a surgical birth. PGE2 gel may be used to ripen the cervix. A cesarean birth may be performed if the client is seriously ill. A pediatrician/neonatologist or neonatal nurse practitioner should be available in the birthing room to care for the newborn. A newborn whose mother received high doses of magnesium sulfate needs to be monitored for respiratory depression, hypocalcemia, and hypotonia. Decreased fetal heart rate variability may occur but, in general, magnesium sulfate does not pose a risk to the fetus. The newborn may exhibit respiratory depression, loss of reflexes, muscle weakness, and neurologic depression (Martin, Fanaroff, & Walsh, 2014). MANAGEMENT OF ECLAMPSIA In the woman who develops an eclamptic seizure, the convulsive activity begins with facial twitching, followed by generalized muscle rigidity. The woman’s face initially may become distorted, with protrusion of the eyes, and foaming at the mouth may occur. Respirations cease for the duration of the seizure, resulting from muscle spasms, thus compromising fetal oxygenation. Seizure complications can include tongue biting, head trauma, broken bones, and aspiration. Coma usually follows the seizure activity, with respiration resuming. Eclamptic seizures are life-threatening emergencies and require immediate treatment to decrease maternal morbidity and mortality. As with any seizure, the initial management is to clear the airway and administer adequate oxygen. Positioning the woman on her left side and protecting her from injury during the seizure are the key. Suction equipment must be readily available to remove secretions from her mouth after the seizure is over. Intravenous fluids are administered after the seizure at a rate to replace urine output and additional insensible losses. Fetal heart rate is monitored closely. Magnesium sulfate is administered intravenously to prevent further seizures. Serum magnesium levels, respiratory rate, reflexes, and urine output in women receiving magnesium sulfate are closely monitored to avoid magnesium toxicity and prevent cardiac arrest. Calcium gluconate (1 g intravenously) is typically ordered to counteract magnesium toxicity. Hypertension is controlled with antihypertensive medications. After the woman’s seizures are controlled, her stability is assessed. If she is found stable, birth via induction or cesarean birth is performed (Amorim et al., 2015). If the woman’s condition remains stable, she will be transferred to the postpartum unit for care. If she becomes

unstable after giving birth, she may be transferred to the critical care unit for closer observation.

Nursing Assessment Preventing complications related to preeclampsia requires the use of assessment, advocacy, and counseling skills. Assessment begins with the accurate measurement of the client’s blood pressure at each encounter. In addition, nurses need to assess for subjective complaints that may indicate progression of the disease—visual changes, severe headaches, unusual bleeding or bruising, or epigastric pain (Nagtalon-Ramos, 2014). The significant signs of preeclampsia— proteinuria and hypertension—occur without the woman’s awareness. Unfortunately, by the time symptoms are noticed, gestational hypertension can be severe.

Take Note! The absolute blood pressure (value that validates elevation) of 140/90 mm Hg should be obtained on two occasions 4 to 6 hours apart to be diagnostic of preeclampsia. Proteinuria is defined as 300 mg or more of urinary protein per 24 hours or more than 1+ protein by chemical reagent strip or dipstick of at least two random urine samples collected at least 4 to 6 hours apart with no evidence of urinary tract infection (ACOG, 2014c). HEALTH HISTORY AND PHYSICAL EXAMINATION Take a thorough history during the first antepartal visit to identify whether the woman is at risk for preeclampsia. Risk factors include: • Primigravida status • Chromosomal abnormalities • Structural congenital anomalies • Multiple gestation • History of preeclampsia in a previous pregnancy • Excessive placental tissue, as is seen in women with GTD • Chronic stress

• Use of ovulation drugs • Family history of preeclampsia (mother or sister) • Lower socioeconomic status • History of diabetes, hypertension, or renal disease • Poor nutrition • Lower socioeconomic status • African–American ethnicity • Age extremes (younger than 20 or older than 35) • Obesity (Ross, 2015). In addition, complete a nutritional assessment that includes the woman’s usual intake of protein, calcium, daily calories, and fluids. Women at risk for preeclampsia require more frequent prenatal visits throughout their pregnancy, and they require teaching about problems so that they can report them promptly. Blood pressure must be measured carefully and consistently. Obtain all measurements with the woman in the same position (blood pressure is highest in the sitting position and lowest in the side-lying position) and by using the same technique (automated vs. manual). This standardization in position and technique will yield the most accurate readings (Norwitz, 2015). Obtain the client’s weight (noting gain since last visit), and assess for amount and location of edema. Asking questions such as “Do your rings still fit on your fingers?” or “Is your face puffy when you get up in the morning?” will help to determine whether fluid retention is present or if the woman’s status has changed since her last visit.

Take Note! Although edema is not a cardinal sign of preeclampsia, weight should be monitored frequently to identify sudden gains in a short time span. Current research relies less on the classic triad of symptoms (hypertension, proteinuria, and edema or weight gain) and more on decreased organ perfusion, endothelial dysfunction (capillary leaking and proteinuria), and elevated blood pressure as key indicators (Carson & Gibson, 2015).

If edema is present, assess the distribution, degree, and pitting. Document your findings and identify whether the edema is dependent or pitting. Dependent edema is present on the lower half of the body if the client is ambulatory, where hydrostatic pressure is greatest. It is usually observed in the feet and ankles or in the sacral area if the client is on bed rest. Pitting edema is edema that leaves a small depression or pit after finger pressure is applied to a swollen area (Carson & Gibson, 2014). Record the depth of pitting demonstrated when pressure is applied. Although subjective, the following is used to record relative degrees: • 1+ pitting edema = 2-mm depression into skin; disappears rapidly • 2+ pitting edema = 4-mm skin depression; disappears in 10 to 15 seconds • 3+ pitting edema = 6-mm depression into skin; lasts more than 1 minute • 4+ pitting edema = 8-mm depression into skin; lasts 2 to 3 minutes At every antepartal visit, assess the fetal heart rate with a Doppler device. Also check a clean-catch urine specimen for protein using a dipstick. LABORATORY AND DIAGNOSTIC TESTING Various laboratory tests may be performed to evaluate the woman’s status. Typically these include a CBC, serum electrolytes, BUN, creatinine, and hepatic enzyme levels. Urine specimens are checked for protein; if levels are 1 to 2+ or greater, a 24-hour urine collection is completed.

Nursing Management Nursing management of the woman with preeclampsia focuses on close monitoring of blood pressure and ongoing assessment for evidence of disease progression. Throughout the client’s pregnancy, fetal surveillance is essential. INTERVENING FOR PREECLAMPSIA The woman with mild preeclampsia requires frequent monitoring to detect changes because preeclampsia can progress rapidly. Instruct all women in the signs and symptoms of preeclampsia and urge them to contact their health care professional for immediate evaluation should any occur. Typically, women with mild preeclampsia can be managed at home if they have a good understanding of the disease process, blood pressure and vital signs are stable, there are no abnormal laboratory test results, and if good fetal

movement is demonstrated (Teaching Guidelines 19.2). The home care nurse makes frequent visits and follow-up phone calls to assess the woman’s condition, to assist with scheduling periodic evaluations of the fetus (such as nonstress tests), and to evaluate any changes that might suggest a worsening of the woman’s condition.

Teaching Guidelines 19.2

TEACHING FOR THE WOMAN WITH MILD PREECLAMPSIA • Rest in a quiet environment to prevent cerebral disturbances. • Drink 8 to 10 glasses of water daily. • Consume a balanced, high-protein diet including high-fiber foods. • Obtain intermittent bed rest to improve circulation to the heart and uterus. • Limit your physical activity to promote urination and subsequent decrease in blood pressure. • Enlist the aid of your family so that you can obtain appropriate rest time. • Perform self-monitoring as instructed, including: • Taking your own blood pressure twice daily • Checking and recording weight daily • Performing urine dipstick twice daily • Recording the number of fetal kicks daily • Contact the home health nurse if any of the following occurs: • Increase in blood pressure • Protein present in urine • Gain of more than 1 lb in 1 week • Burning or frequency when urinating • Decrease in fetal activity or movement • Headache (forehead or posterior neck region)

• Dizziness or visual disturbances • Increase in swelling in hands, feet, legs, and face • Stomach pain, excessive heartburn, or epigastric pain • Decreased or infrequent urination • Contractions or low back pain • Easy or excessive bruising • Sudden onset of abdominal pain • Nausea and vomiting Early detection and management of mild preeclampsia is associated with the greatest success in reducing progression of this condition. As long as the client carries out the guidelines of care as outlined by the health care provider and remains stable, home care can continue to maintain the pregnancy until the fetus is mature. If disease progression occurs, hospitalization is required. INTERVENING FOR SEVERE PREECLAMPSIA The woman with severe preeclampsia requires hospitalization. Maintain the client on complete bed rest in the left lateral lying position. Ensure that the room is dark and quiet to reduce stimulation. Give sedatives as ordered to encourage quiet bed rest. The client is at risk for seizures if the condition progresses. Therefore, institute and maintain seizure precautions, such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury.

Take Note! Preeclampsia increases the risk of placental abruption, preterm birth, intrauterine growth restriction, and fetal distress during childbirth. Always be prepared if you see symptoms of preeclampsia! Closely monitor the client’s blood pressure. Administer antihypertensives as ordered to reduce blood pressure (Drug Guide 19.3). Assess the client’s vision and level of consciousness. Report any changes and any complaints of headache

or visual disturbances. Offer a high-protein diet with 8 to 10 glasses of water daily. Monitor the client’s intake and output every hour and administer fluid and electrolyte replacements as ordered. Assess the woman for signs and symptoms of pulmonary edema, such as crackles and wheezing heard on auscultation, dyspnea, decreased oxygen saturation levels, cough, neck vein distention, anxiety, and restlessness. The treatment of acute pulmonary edema is symptomatic and includes the administration of vasodilating agents and of diuretics. The development of acute pulmonary edema in women with hypertension during pregnancy is associated with high levels of intravenous fluid administration (Pauli & Repke, 2015). To achieve a safe outcome for the fetus, prepare the woman for possible testing to evaluate fetal status as preeclampsia progresses. Testing may include the nonstress test, serial ultrasounds to track fetal growth, amniocentesis to determine fetal lung maturity, Doppler velocimetry to screen for fetal compromise, and biophysical profile to evaluate ongoing fetal well-being (Mattson & Smith, 2016). Other laboratory tests may be performed to monitor the disease process and to determine if it is progressing into HELLP syndrome. These include liver enzymes such as lactic dehydrogenase (LDH), ALT, and AST; chemistry panel, such as creatinine, BUN, uric acid, and glucose; CBC, including platelet count; coagulation studies, such as PT, PTT, fibrinogen, and bleeding time; and a 24hour urine collection for protein and creatinine clearance.

DRUG GUIDE 19.3 MEDICATIONS USED WITH PREECLAMPSIA AND ECLAMPSIA

Administer parenteral magnesium sulfate as ordered to prevent seizures. Assess DTRs to evaluate the effectiveness of therapy. Clients with preeclampsia commonly present with hyperreflexia. Severe preeclampsia causes changes in the cortex, which disrupts the equilibrium of impulses between the cerebral cortex and the spinal cord. Brisk reflexes (hyperreflexia) are the result of an irritable cortex and indicate CNS involvement (Marik, 2015). Diminished or absent reflexes occur when the client develops magnesium toxicity. Because magnesium is a potent neuromuscular blockade, the afferent and efferent nerve pathways do not relay messages properly and hyporeflexia develops. Common sites used to assess DTRs are biceps reflex, triceps reflex, patellar reflex, Achilles reflex, and plantar reflex. Nursing Procedure 19.1 highlights the steps for assessing the patellar reflex. The National Institute of Neurological Disorders and Stroke, a division of the National Institutes of Health, published a scale in the early 1990s that, although subjective, is used widely today. It grades reflexes from 0 to 4+. Grades 2+ and 3+ are considered normal, whereas grades 0 and 4 may indicate pathology (Table 19.2). Because these are subjective assessments, to improve communication of reflex results, condensed descriptor categories such as absent, average, brisk, or clonus should be used rather than numeric codes (Magowan, Owen, & Thomson, 2014). Clonus is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms CNS involvement. Nursing Procedure 19.2 highlights the steps when testing for ankle clonus. With magnesium sulfate administration, the client is at risk for magnesium toxicity. Closely assess the client for signs of toxicity, which include a respiratory rate of less than 12 breaths per minute, absence of DTRs, and a decrease in urinary output (160 mm Hg systolic and >100 mm Hg diastolic. Methyldopa (Aldomet) is commonly prescribed because of its safety record during pregnancy. This slow-acting antihypertensive agent helps to improve uterine perfusion. Other antihypertensive agents that can be used include labetalol (Trandate), atenolol (Tenormin), and nifedipine (Procardia) (Foo et al., 2015). The U.S. Preventive Services Task Force [USPTF] (2015) recommends daily low-dose aspirin (81 mg/day) after 12 weeks of pregnancy in women, with chronic hypertension and other risk factors, who are at high risk for preeclampsia to reduce its occurrence. Lifestyle changes are needed and should continue throughout gestation. The woman with chronic hypertension will be seen more frequently (every 2 weeks until 28 weeks and then weekly until birth) to monitor her blood pressure and to assess for any signs of preeclampsia. At approximately 24 weeks of gestation, the woman will be instructed to document fetal movement. At this same time, serial ultrasounds will be ordered to monitor fetal growth and amniotic fluid volume. Additional tests will be included if the client’s status changes.

Nursing Assessment Nursing assessment of the woman with chronic hypertension involves a thorough history and physical examination. Review the woman’s history closely for risk factors. The pathogenesis of hypertension is multifactorial and includes many modifiable risk factors such as smoking, obesity, caffeine intake, excessive alcohol intake, excessive salt intake, and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Also be alert for nonmodifiable risk factors such as increasing age and African–American race (Miller & Carpenter, 2015). Ask if the woman has received any preconception counseling and what measures have been used to prevent or control hypertension. Assess the woman’s vital signs, in particular her blood pressure. Evaluate her blood pressure in all three positions (sitting, lying, and standing) and note any major differences in the readings. Assess her for orthostatic hypertension when she changes her position from sitting to standing. Document your findings.

Ask the woman if she monitors her blood pressure at home; if so, inquire about the typical readings. Ask the woman if she uses any medications for blood pressure control, including the drug, dosage, and frequency of administration, as well as any side effects. Ask the woman about lifestyle modifications that she has used to address any modifiable risk factors, and their effectiveness. Hypertension during pregnancy decreases uteroplac-ental perfusion. Therefore, fetal well-being must be assessed and closely monitored. Anticipate serial ultrasounds to assess fetal growth and amniotic fluid volume. Question the woman about fetal movement and evaluate her report of daily “kick counts.” Assess fetal heart rate at every visit.

Nursing Management Preconception counseling is the ideal time to discuss lifestyle changes to prevent or control hypertension. One area to cover during this visit would be the Dietary Approaches to Stop Hypertension (DASH) diet, which contains an adequate intake of potassium, magnesium, and calcium. Sodium is usually limited to 2.4 g. Suggest aerobic exercise as tolerated. Encourage smoking cessation and avoidance of alcohol. If the woman is overweight, encourage her to lose weight before becoming pregnant, not during the pregnancy (Killion, 2015). Stressing the positive benefits of a healthy lifestyle might help motivate the woman to make the necessary modifications and change unhealthy habits. Assist the woman in scheduling appointments for antepartum visits every 2 weeks until 28 weeks of gestation and then weekly. Prepare the woman for frequent fetal assessments. Explaining the rationale for the need to monitor fetal growth is important to gain the woman’s cooperation. Carefully monitor the woman for signs and symptoms of abruptio placenta (abdominal pain, rigid abdomen, vaginal bleeding), as well as superimposed preeclampsia (elevation in blood pressure, weight gain, edema, proteinuria). Alerting the woman to these risks can mean early identification and prompt intervention. Stress the importance of daily periods of rest (1 hour) in the left lateral recumbent position to maximize placental perfusion. Encourage women with chronic hypertension to use home blood pressure monitoring devices. Urge the woman to report any elevations. As necessary, instruct the woman and her family how to take and record a daily blood pressure, and reinforce the need for her to take her medications as prescribed to control her blood pressure and to ensure the well-being of her unborn child. Praising her for her efforts at each

prenatal visit may motivate her to continue the regimen throughout her pregnancy. The close monitoring of the woman with chronic hypertension continues during labor and birth and during the postpartum period to prevent or identify the onset of preeclampsia. Accurate and frequent blood pressure readings and careful administration of antihypertensive medications, if prescribed, are essential components of care. Stressing the need for continued medical supervision after childbirth is vital to motivate the woman to maintain or initiate lifestyle changes and dietary habits and stay compliant with her medication regimen.

RESPIRATORY CONDITIONS During pregnancy, the respiratory system is affected by hormonal changes, mechanical changes, and prior respiratory conditions. These changes can cause a woman with a history of compromised respiration to decompensate during pregnancy. Although upper respiratory infections are typically self-limiting, chronic respiratory conditions, such as asthma or tuberculosis (TB), can have a negative effect on the growing fetus when alterations in oxygenation occur in the mother. The outcome of pregnancy in a woman with a respiratory condition depends on the severity of the oxygen alteration as well as the degree and duration of hypoxia on the fetus.

Asthma Worldwide, the prevalence of asthma among pregnant women is on the rise; pregnancy leads to a worsening of asthma for many women (Nagtalon-Ramos, 2014). Asthma affects approximately up to 13% of pregnancies globally, ranging between 200,000 and 376,000 women annually in the United States. It affects over 20 million Americans and is one of the most common and potentially serious medical conditions to complicate pregnancy (Jordan et al., 2014). Maternal asthma is associated with an increased risk of infant death, preeclampsia, intrauterine growth restriction (IUGR), preterm birth, and low birth weight. These risks are linked to the severity of asthma: more severe asthma increases the risk (National Asthma Education and Prevention Program [NAEPP], 2015). Remember Rose, the pregnant teenager with asthma in acute distress described at the beginning of the chapter? What therapies might be offered to control her symptoms? Should she be treated differently than someone who is not pregnant? Why or why not?

Pathophysiology Asthma is an allergic-type inflammatory response of the respiratory tract to various stimuli such as allergens (pollen and animal dander), irritants (cigarette smoke and chemicals), stress, infections (colds or flu), and physical exertion. It is also known as reactive airway disease because the bronchioles constrict in response to these stimuli. Asthma is characterized by paroxysmal or persistent symptoms of bronchoconstriction including breathlessness, wheezing, chest tightness, cough, and sputum production. In addition to bronchoconstriction, inflammation of the airways produces thick mucus that further limits the movement of air and makes breathing difficult. The normal physiologic changes of pregnancy affect the respiratory system. Although the respiratory rate does not change, hyperventilation increases at term by 48% due to high progesterone levels. Diaphragmatic elevation and a decrease in functional lung residual capacity occur late in pregnancy, which may reduce the woman’s ability to inspire deeply to take in more oxygen. Oxygen

consumption and the metabolic rate both increase, placing additional stress on the woman’s respiratory system (American Academy of Allergy, Asthma, & Immunology [AAAAI], 2015). Both the woman and her fetus are at risk if asthma is not well managed during pregnancy. When a pregnant woman has trouble breathing, her fetus also has trouble getting the oxygen it needs for adequate growth and development. Severe persistent asthma has been linked to the development of maternal hypertension, low birth weight, preterm birth, preeclampsia, placenta previa, uterine hemorrhage, and oligohydramnios. Women whose asthma is poorly controlled during pregnancy are at increased risk of preterm birth, low birth weight, and stillbirth (Vanders & Murphy, 2015). The severity of the condition improves in one third of pregnant women, remains unchanged in one third, and worsens in one third (Cunningham et al., 2014). However, the effect of pregnancy on asthma is unpredictable. The greatest increase in asthma attacks usually occurs between 24 and 36 weeks of gestation; flare-ups are rare during the last 4 weeks of pregnancy and during labor (AAAAI, 2015).

Therapeutic Management Asthma should be treated as aggressively in pregnant women as in nonpregnant women because the benefits of averting an asthma attack outweigh the risks of medications. The ultimate goal of asthma therapy is to prevent hypoxic episodes to preserve continuous fetal oxygenation; improved maternal and perinatal outcomes are achieved with optimal control of asthma. One third of women with asthma develop worsening of control during pregnancy; therefore, close monitoring and reevaluation are essential. Four important aspects of asthma treatment ensure optimal control: close monitoring, education of clients, avoidance of asthma triggers, and pharmacologic therapy. Many women with asthma have positive skin tests to allergens, the most common being animal dander, dust mites, cockroach antigens, pollens, and molds. There are nonimmune triggers as well, including strong odors, tobacco smoke, air pollutants, and drugs such as aspirin and beta-blockers. For exercisetriggered asthma, the use of a bronchodilator 5 to 60 minutes before exercise may reduce symptoms. Avoidance of these allergens and triggers can significantly reduce the need for medication and the occurrence of exacerbations during and after pregnancy. All women should be strongly encouraged to stop

smoking, but especially those with asthma because they are at increased risk for worsening chronic and acute asthma sequelae. Allergy injections may benefit those with allergies and asthma, called allergic asthma. Also called immunotherapy, allergy shots do not “cure” asthma in the manner in which an injection of, say, antibiotics might cure an infection. Instead, allergy shots work a bit more like a vaccine. Allergy injections for asthma actually contain a very small amount of an allergen (substance causing allergy). Over time, the dosage is increased. Exposure to progressive amounts of the allergen is likely to help the body develop a tolerance to it. If the allergen buildup is effective, the allergic reaction will become much less severe. Allergy injections can reduce the symptoms of allergies and prevent the development of asthma. Medical therapy includes a stepwise approach in an attempt to use the least amount of medication necessary to control a woman’s asthma and keep her severity in the mild range. Goals of therapy include having normal or nearnormal pulmonary function and minimal or no chronic symptoms, exacerbations, or limitations on activities. The final goal is to minimize the adverse effects of treatment. Inhaled corticosteroids are preferred for the management of all levels of persistent asthma in pregnancy. Corticosteroids are the most effective treatment for the airway inflammation of asthma and reduce the hyperresponsiveness of airways to allergens and triggers. NAEPP (2015) recommends three specific drugs to be used during pregnancy to control asthma: • Budesonide (inhaled corticosteroid) • Albuterol (short-acting beta2 agonist) • Salmeterol (long-acting beta2 agonist) Oral corticosteroids are not recommended for the long-term treatment of asthma during pregnancy, but they can be used to treat severe asthma attacks during pregnancy (AAAAI, 2015). In addition, two prostaglandins (hemabate and misoprostol [Cytotec]) used for treating postpartum hemorrhage and cervical ripening are contraindicated for clients with asthma due to the risk of bronchial spasm and bronchoconstriction (King et al., 2015).

Nursing Assessment Obtain a thorough history of the disease, including the woman’s usual therapy

and control measures. Question the woman about asthma triggers and strategies used to reduce exposure to them (Box 20.2). Review the client’s medication therapy regimen. Auscultate the lungs and assess respiratory and heart rates. Include the rate, rhythm, and depth of respirations; skin color; blood pressure and pulse rate; and signs of fatigue. Clients with an acute asthma attack often present with wheezing, chest tightness, tachypnea, nonproductive coughing, shortness of breath, and dyspnea. Lung auscultation findings might include diffuse wheezes and rhonchi, bronchovesicular sounds, and a more prominent expiratory phase of respiration compared to the inspiratory phase (Kelly, Massoumi, & Lazarus, 2015). If the pregnancy is far enough along, the fetal heart rate is measured and routine prenatal assessments (weight, blood pressure, fundal height, urine for protein) are completed.

BOX 20.2 COMMON ASTHMA TRIGGERS • Smoke and chemical irritants • Air pollution • Dust mites • Animal dander • Seasonal changes with pollen, molds, and spores • Upper respiratory infections • Esophageal reflux • Medications, such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) • Exercise • Cold air • Emotional stress Adapted from American Academy of Allergy, Asthma & Immunology [AAAAI]. (2015). Asthma and pregnancy.

Retrieved

from

http://www.aaaai.org/conditions-and-treatments/library/asthma-

library/asthma-and-pregnancy.aspx; March of Dimes(2015l). Asthma during pregnancy. Retrieved from http://www.marchofdimes.org/pregnancy/asthma-during-pregnancy.aspx; and Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C., & Dashe, J. (2014). Williams’ obstetrics (24th ed.). New York, NY: McGraw-Hill Professional Publishing.

Laboratory studies usually include a complete blood count with differential (to assess the degree of nonspecific inflammation and identify anemia) and pulmonary function tests (to assess the severity of an attack and to provide a baseline to evaluate the client’s response to treatment).

Nursing Management Nursing management focuses on client education about the condition and the skills necessary to manage it: self-monitoring, correct use of inhalers, identifying

and limiting exposure to asthma triggers, and following a long-term plan for managing asthma and for promptly handling signs and symptoms of worsening asthma. Client education fosters adherence to the treatment regimen, thereby promoting an optimal environment for fetal growth and development. Client education should begin at the first prenatal visit. The importance of optimal asthma control and the risks of poor control for the woman and her fetus should be discussed early in pregnancy. Clients should be taught signs and symptoms, and which should be of concern, as well as who to contact in emergent situations. Women should be observed using their inhalers and correct use reinforced. Frank discussion about the importance of continuing asthma medications and the possible severe consequences for the woman and her fetus with discontinuation is vital. Ensure that the woman understands drug actions and interactions, the uses and potential abuses of asthma medications, and the signs and symptoms that require medical evaluation. Reviewing potential perinatal complications with the woman is helpful in motivating her to adhere to the prescribed regimen. At each antepartum visit, reassess the efficacy of the treatment plan to determine whether adjustments are needed. Taking control of asthma in pregnancy is the responsibility of the client along with her health care team. Providing the client with the knowledge and tools to monitor her condition, control triggers and her environment (Teaching Guidelines 20.2), and use medications to prevent acute exacerbations assist the client in taking control. Facilitating a partnership with the woman will improve perinatal outcomes.

Teaching Guidelines 20.2

TEACHING TO CONTROL ASTHMA LINKED TO ENVIRONMENTAL TRIGGERS • Remove any carpeting in the house, especially the bedroom, to reduce dust mites. • Use allergen-proof encasing on the mattress, box spring, and pillows. • Wash all bedding in hot water.

• Remove dust collectors in house, such as stuffed animals, books, knickknacks. • Avoid pets in the house to reduce exposure to pet dander. • Keep humidity 292 days) dated from the last menstrual period. Approximately 10% of low risk pregnancies continue beyond the 42nd week gestation. Her fetal well-being assessment is within normal limits. Go to

to find questions to consider about this case.

22 Nursing Management of the Postpartum Woman at Risk

KEY TERMS mastitis metritis postpartum depression (PPD) postpartum hemorrhage (PPH) subinvolution uterine atony

Learning Objectives Upon completion of the chapter, you will be able to: 1. Examine the major conditions that place the postpartum woman at risk. 2. Analyze the risk factors, assessment, preventive measures, and nursing management of common postpartum complications. 3. Differentiate the causes of postpartum hemorrhage based on the underlying pathophysiologic mechanisms. 4. Outline the nurse’s role in assessing and managing the care of a woman with a thromboembolic condition. 5. Characterize the nursing management of a woman who develops a postpartum infection. 6. Compare and contrast at least two affective disorders that can occur in women after birth, describing specific therapeutic management for each. Joan gave birth about an hour ago to her fifth baby boy, who weighed 10 pounds, and she is resting in bed when the nurse comes in to assess her. She tells the nurse that she feels like there is “something really wet” between her legs. She also feels a bit light-headed. What would the nurse suspect is happening? What findings would support the nurse’s suspicion? What should the nurse do first?

Words of Wisdom Nurses should remain vigilant and observant throughout the childbirth experience all the way through discharge of the childbearing family.

INTRODUCTION The postpartum period is the culmination of the childbearing experience. Numerous adaptations and adjustments must be made to assimilate the newborn into the established family unit. It is a time designed for maternal recovery, family attachment, and new role development. Typically, recovery from childbirth progresses normally both physiologically and psychologically. Just like everything else in life, a woman’s body faces significant changes in the weeks and months following childbirth. It is a time filled with many changes and wide-ranging emotions, and the new mother commonly experiences a great sense of accomplishment. However, the woman can experience deviations from the norm, developing a postpartum condition that places her at risk. These highrisk conditions or complications can become life threatening. Healthy People 2020 addresses these risks in two national health goals that were retained from the 2010 document. This chapter addresses the nursing management of the most common conditions that place the postpartum woman at risk: hemorrhage, thromboembolic disease, infections, and postpartum affective disorders.

POSTPARTUM HEMORRHAGE Postpartum hemorrhage (PPH) is a potentially life-threatening complication that can occur after both vaginal and cesarean births. It is the leading cause of maternal death in both developed and developing countries, accounting for about 35% of all maternal deaths. Every year about 14 million women globally suffer from PPH or approximately one in twenty births Agency for Healthcare Research and Quality [AHRQ], 2015). A hemorrhage occurs in 5% of all births and is responsible for a major part of maternal mortality. The majority of these deaths occur within 4 hours of childbirth, which indicates that they are a consequence of the third stage of labor management (Crowe & Faulkner, 2014; Ekin et al., 2015).

HEALTHY PEOPLE 2020 • 22.1

PPH is defined as a blood loss greater than 500 mL after vaginal birth or more than 1,000 mL after a cesarean birth. However, this definition is arbitrary, because estimates of blood loss at birth are subjective and generally inaccurate. Moreover, average blood loss from birth frequently exceeds 500 or 1,000 mL, and symptoms of hemorrhage or shock from blood loss may be hidden by normal plasma volume increases that occur during pregnancy. Morbidity from PPH can be severe, with sequelae including organ failure, shock, edema, thrombosis, acute respiratory distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization (AHRQ, 2015). A major obstetric hemorrhage is defined as a blood loss of more than 1,500 to 2,500 mL or bleeding that required more than 5 units of transfused blood (Pavord & Maybury, 2015). Hemorrhage is the most common reason postpartum women are admitted to intensive care units

and it is the most preventable cause of maternal death. Timely, accurate identification and initiation of appropriate interventions would improve outcomes (Clapp, 2015). Blood loss that occurs within 24 hours of birth is termed primary (immediate or early) postpartum hemorrhage; blood loss that occurs 24 hours to 12 weeks after birth is termed delayed (late) postpartum hemorrhage. A more objective definition of PPH would be any amount of bleeding that places the mother in hemodynamic jeopardy.

Pathophysiology Excessive bleeding can occur at any time between the separation of the placenta and its expulsion or removal. The most common cause of PPH is uterine atony, failure of the uterus to contract and retract after birth. The uterus must remain contracted after birth to control bleeding from the placental site. Uterine atony is responsible for 80% of primary or immediate PPH, while obstetric lacerations, uterine inversion, and rupture compromise about 20% of all primary or early PPHs (Kamel & Mastrogiannis, 2015). Any factor that causes the uterus to relax after birth will cause bleeding—even a full bladder that displaces the uterus. During the third stage of labor the muscles of the uterus contract downward, causing constriction of the blood vessels that pass through the uterine wall to the placental surface and stopping the flow of blood. This action also causes the placenta to separate from the uterine wall. The absence of uterine contractions may result in excessive blood loss. Uterotonic medications promote uterine contractions to prevent atony and speed delivery of the placenta. Over the course of pregnancy, maternal blood volume increases as much as 50% (from 4 to 6 L). The plasma volume increases twice as much in comparison to the total red blood cell volume. As a result, hemoglobin and hematocrit fall. The increase in blood volume meets the perfusion demands of the low-resistance uteroplacental unit and provides a reserve for the blood loss that occurs at delivery (Cunningham et al., 2014). Given this increase, the typical signs of hemorrhage (e.g., falling blood pressure, increasing pulse rate, and decreasing urinary output) do not appear until as much as 1,800 to 2,100 mL of blood has been lost. Current evidence on postpartum volume replacement suggests packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa be used for volume replacement (Nagtalon-Ramos, 2014). Clinical manifestations of shock resulting from blood loss are seen in Table 22.1. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus, on peripads, mattresses, and the floor. Because no universal clinical standard exists, nurses must remain vigilant, assessing for risk factors and checking clients carefully before the birth attendant leaves the birthing area. Other causes of PPH include lacerations of the genital tract, episiotomy, retained placental fragments, uterine inversion, coagulation disorders, large for gestational age newborn, failure to progress during the second stage of labor,

placenta accreta, induction or augmentation of labor with oxytocin, surgical birth, and hematomas of the vulva, vagina, or subperitoneal areas (Moses, 2015). A helpful way to remember the causes of postpartum hemorrhage is by using the 4 Ts: TABLE 22.1 CLINICAL MANIFESTATIONS OF SHOCK DUE TO BLOOD LOSS

1. Tone: uterine atony, distended bladder 2. Tissue: retained placenta and clots; uterine subinvolution 3. Trauma: lacerations, hematoma, inversion, rupture 4. Thrombin: coagulopathy (pre-existing or acquired)

Tone Altered uterine muscle tone most commonly results from overdistention of the uterus. Overdistention can be caused by multiple gestation, fetal macrosomia, hydramnios, fetal abnormality, placenta previa, precipitous birth, or retained

placental fragments. Other causes might include prolonged or rapid, forceful labor, especially if stimulated by oxytocin; bacterial toxins (e.g., chorioamnionitis, endomyometritis, septicemia); use of anesthesia, especially halothane; and magnesium sulfate used in the treatment of preeclampsia (Jordan et al., 2014). Overdistention of the uterus is a major risk factor for uterine atony, the most common cause of early postpartum hemorrhage, which can lead to hypovolemic shock. A distended bladder can also displace the uterus from the midline to either side, which impedes its ability to contract to reduce bleeding.

Tissue Uterine contraction and retraction lead to detachment and expulsion of the placenta after birth. Classic signs of placental separation include a small gush of blood with lengthening of the umbilical cord and a slight rise of the uterus in the pelvis. Complete detachment and expulsion of the placenta permit continued contraction and optimal occlusion of blood vessels. Failure of complete placental separation and expulsion leads to retained fragments, which occupy space and prevent the uterus from contracting fully to clamp down on blood vessels; this can lead to hemorrhage. Clots can also occupy space, which inhibits uterine contractions. After the placenta has been expelled, a thorough inspection is necessary to confirm its intactness; tears or fragments left inside may indicate an accessory lobe or placenta accreta (an uncommon condition in which the chorionic villi adhere to the myometrium, causing the placenta to adhere abnormally to the uterus and not separate and deliver spontaneously). Profuse hemorrhage results because the uterus cannot contract fully. SUBINVOLUTION OF THE UTERUS Subinvolution refers to incomplete involution of the uterus or failure to return to its normal size and condition after birth. Typically, subinvolution occurs when the myometrial fibers of the uterus do not contract effectively and causes relaxation. Complications of subinvolution include hemorrhage, pelvic peritonitis, salpingitis, and abscess formation (King et al., 2015). Causes of subinvolution include retained placental fragments, distended bladder, excessive maternal activity prohibiting proper recovery, uterine myoma, and infection. All of these conditions contribute to delayed postpartum bleeding. The clinical picture includes a postpartum fundal height that is higher than expected, with a

boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. This condition is usually identified at the woman’s postpartum examination 4 to 6 weeks after birth with a bimanual vaginal examination or ultrasound. Treatment is directed toward stimulating the uterus to expel fragments with a uterine stimulant, and antibiotics are given to prevent infection.

Trauma Damage to the genital tract may occur spontaneously or through the manipulations used during birth. Lacerations and hematomas resulting from birth trauma can cause significant blood loss. Hematomas can present as pain or as a change in vital signs disproportionate to the amount of blood loss. Most often, hematoma formation is associated with episiotomy, instrumental birth, or nulliparity. Many hematomas can be prevented with gentle, controlled birth, and appropriate inspection and repair of lacerations or episiotomy (Jordan et al., 2014). Uterine inversion happens when the top of the uterus collapses into the inner cavity due to excessive fundal pressure or pulling on the umbilical cord when the placenta is still firmly attached to the fundus after the infant has been born. Treatment for uterine inversion includes giving uterine relaxants and immediate manual replacement by the health care provider. Additionally, uterine rupture can occur and cause damage to the genital tract and is more common in women with previous cesarean incisions or those who have undergone any procedure resulting in disruption of the uterine wall, including myomectomy, perforation of the uterus during a dilation and curettage, biopsy, or intrauterine system insertion. Classically, its signs and symptoms combine pain, fetal heart rate abnormalities, and vaginal bleeding. Uterine rupture is a catastrophic complication that requires a rapid diagnosis and intervention, but initial clinical manifestations may be nonspecific (Nahum & Pham, 2015). Trauma can also occur after prolonged or vigorous labor, especially if the uterus has been stimulated with oxytocin or prostaglandins. Trauma can also occur after extrauterine or intrauterine manipulation of the fetus. Cervical lacerations commonly occur during a forceps delivery or in mothers who have not been able to resist bearing down before the cervix is fully dilated. Vaginal sidewall lacerations are associated with operative vaginal births but may occur spontaneously, especially if the fetal hand presents with the head. Lacerations can arise during manipulations to resolve shoulder dystocia. Lacerations should always be suspected in the face of a contracted uterus with

bright-red blood continuing to trickle out of the vagina.

Thrombin Thrombosis (formation of a blood clot) helps to prevent PPH immediately after birth by providing hemostasis. Fibrin deposits and clots in supplying vessels play a significant role in the hours and days after birth. Disorders that interfere with the clot formation can lead to postpartum hemorrhage. Medication used to prevent hemorrhage by stimulating uterine contractions may delay the appearance of coagulation disorders. Coagulopathies should be suspected when postpartum bleeding persists without any identifiable cause (Agency for Healthcare Research and Quality [AHRQ], 2015). Disorders of coagulation are relatively uncommon as a sole cause of PPH. Coagulation disturbances should be suspected in women with a family history of such abnormalities and women with a history of menorrhagia. Clinical circumstances may also suggest coagulation defect as a cause of PPH. Diagnosis of a coagulation disorder often requires a high index of suspicion and should not be overlooked in the evaluation of obstetric hemorrhage (Yiadom & Carusi, 2015). Ideally, the client’s coagulation status is determined during pregnancy. However, if she received no prenatal care, coagulation studies should be ordered immediately to determine her status. Abnormal results typically include decreased platelet and fibrinogen levels, increased prothrombin time, partial thromboplastin time, and fibrin degradation products, and a prolonged bleeding time (Cunningham et al., 2014). Selected conditions associated with coagulopathies in the postpartum client include idiopathic thrombocytopenic purpura, von Willebrand disease, and disseminated intravascular coagulation (DIC). IDIOPATHIC THROMBO PURPURA Idiopathic thrombocytopenia purpura (ITP) is an autoimmune disorder of increased platelet destruction caused by autoantibodies, which can increase a woman’s risk of hemorrhaging. There is a decrease in the number of circulating platelets in the absence of toxic exposure or a disease associated with a low platelet count. It is most common in young women during childbearing age and may be associated with maternal and fetal complications. The incidence of ITP in adults is approximately 66 cases per 1,000,000 per year (Silverman, 2015).

Glucocorticoids and immune globulin are the mainstays of medical therapy (Kessler & Sandler, 2015). VON WILLEBRAND DISEASE von Willebrand disease is a congenital bleeding disorder that is inherited as an autosomal dominant trait. It is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion Centers for Disease Control and Prevention [CDC], 2015a). It is the most common hereditary bleeding disorder, affecting approximately 1% of the general population (National Hemophilia Foundation, 2015). Although vWD is thought to affect men and women equally, it is diagnosed more frequently in women because of menorrhagia, and it is more common among white women than African-American women American College of Obstetrics and Gynecologists [ACOG], 2014a). Most cases remain undiagnosed due to lack of awareness, difficulty in diagnosis, a tendency to attribute bleeding to other causes, and variable symptoms. The most common symptoms of vWD include bleeding gums, easy bruising, menorrhagia, blood in urine and stools, nosebleeds and hematomas. Prolonged bleeding from trivial wounds, oral cavity bleeding, and excessive menstrual bleeding are common. Gastrointestinal bleeding is rare. During pregnancy, the von Willebrand factor level increases in most women; thus, labor and birth usually proceed normally. However, all women should be monitored for excessive bleeding, particularly during the first week postpartum (Pollak, 2015). DISSEMINATED INTRAVASCULAR COAGULATION DIC is a life-threatening, acquired coagulopathy in which the clotting system is abnormally activated, resulting in widespread clot formation in the small vessels throughout the body, which leads to the depletion of platelets and coagulation factors. This is why DIC is also known as consumption coagulopathy. DIC is not itself a specific illness; rather it is always a secondary diagnosis that occurs as a complication of abruptio placentae, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, acute fatty liver of pregnancy, severe preeclampsia, HELLP syndrome (hemolysis, i.e., the breakdown of red blood cells, elevated liver enzymes, and low platelet count), septicemia, and postpartum hemorrhage. Clinical features include petechiae, ecchymoses, bleeding gums, fever, hypotension, acidosis, hematomas, tachycardia, proteinuria, uncontrolled bleeding during birth, and acute renal

failure (Levi & Schmaier, 2015).Treatment goals are to maintain tissue perfusion through aggressive administration of fluid therapy, oxygen, heparin, and blood products. The most important treatment concept in DIC is that it is a secondary manifestation of an underlying disorder. The most important therapeutic maneuver is treating the initiating disorder, DIC will disappear, and the coagulation status will normalize Without this, supportive measures ultimately fail (Erez, Mastrolia, & Thachil, 2015).

Therapeutic Management Prompt diagnosis and understanding of the underlying triggers of this complication is essential for a favorable outcome. Team work and prompt treatment are essential for the successful management of women with DIC. Therapeutic management focuses on the underlying cause of the hemorrhage. For example, uterine massage is used to treat uterine atony. If retained placental fragments are the cause, the fragments are usually manually separated and removed and a uterine stimulant is given to promote the uterus to expel fragments. Antibiotics are administered to prevent infection. Lacerations are sutured or repaired. Glucocorticoids and intravenous immunoglobulin, intravenous anti-RhoD, and platelet transfusions may be given for ITP. Perinatal management of ITP should also include maintenance of maternal platelet count and regular monitoring of fetal growth along with prediction and prevention of fetal passive immune thrombocytopenia (Silverman, 2015). The mainstays of therapy for vWD are desmopressin and plasma concentrates that contain von Willebrand factor. Delayed postpartum hemorrhage may occur, despite adequate prophylaxis. Frequent monitoring and continued prophylaxis and/or treatment are recommended for at least 2 weeks after childbirth (Pollak, 2015).

Nursing Assessment Most women will not have identifiable risk factors. Nonetheless, primary prevention of a PPH begins with an assessment of identifiable risk factors. Pregnancy and childbirth involve significant health risks, even for women with no pre-existing health problems. In the United States, where most births occur in hospitals and where resources are likely to be available as compared with developing countries, PPH still continues to be among the top causes of maternal deaths. Retrospective studies of these events suggest that some cases are preventable. As with many other sources of perinatal harm, delays in recognition, diagnosis, and treatment, problems with hierarchy and communication, and lack of knowledge, policies, and protocols were often cited as contributing factors (Shields et al., 2015). The period after the birth and the first hours postpartum are crucial times for the prevention, assessment, and management of bleeding. Compared with other maternal risks such as infection, bleeding can rapidly become life threatening, and nurses, along with other health care providers, need to identify this condition quickly and intervene appropriately. Begin by reviewing the mother’s history, including labor and birth history, for risk factors associated with PPH (Table 22.2). The incidence of PPH has been rising, though the mortality has come down, suggesting improvement in the management of this condition. Although specific risk factors have been identified, PPH is often unanticipated and still occurs in approximately 5% of all births and increasing (Ekin et al., 2015). TABLE 22.2 Factors Placing A Woman at Risk for Postpartum Hemorrhage

Since the most common cause of immediate severe PPH is uterine atony (failure of the uterus to contract properly after birth), assess uterine tone after birth by palpating the fundus for firmness and location. A soft, boggy fundus indicates uterine atony.

Take Note! A soft, boggy uterus that deviates from the midline suggests that a full bladder is interfering with uterine involution. If the uterus is not in correct position (midline), it will not be able to contract to control bleeding.

Assess the amount of bleeding. Visual estimation is the most frequently practiced method of determining blood loss during childbirth in the United States, and the results are usually included in the documentation of events pertaining to the birth. This method is used despite repeated studies showing its inaccuracy and underestimation. Weighing or counting peri pads or using a Signaling a Postpartum Hemorrhage Emergency mat would provide a more accurate estimate of blood loss. The mat was constructed so that each square on the mat would absorb up to 50 mL of blood. Blood loss is then calculated by multiplying the number of blood-saturated squares by 50 mL (Wilcox et al., 2015). In any method used, nurses should consult their hospital protocols and follow them. If bleeding continues even though there are no lacerations, suspect retained placental fragments. The uterus remains large with painless, dark-red bleeding mixed with clots. This cause of hemorrhage can be prevented by carefully inspecting the placenta for intactness. If trauma is suspected, attempt to identify the source and document it. Typically, the uterus will be firm with a steady stream or trickle of unclotted bright-red blood noted in the perineum. Most deaths from PPH are not due to gross bleeding, but rather to inadequate management of slow, steady blood loss (Clapp, 2015). Assess for hematoma which may require surgical treatment. The uterus would be firm, with bright-red bleeding. Observe for a localized bluish bulging area just under the skin surface in the perineal area (Fig. 22.1). Often the woman will report severe perineal or pelvic pain and will have difficulty voiding. In addition, she may exhibit hypotension, tachycardia, and anemia. Frequently, the health care provider will incise the skin bulge to evacuate the hematoma of trapped blood. A pressure dressing is applied to this area to prevent further bleeding (Green, 2016). Inspect the skin and mucous membranes for gingival bleeding or petechiae and ecchymoses. Check venipuncture sites for oozing or prolonged bleeding. These findings might suggest a coagulopathy as a cause of PPH. Also assess the amount of lochia, which would be much greater than usual. Urinary output would be diminished, with signs of acute renal failure. Vital signs would show an increased pulse rate and a decreased level of consciousness. However, signs of shock do not appear until hemorrhage is far advanced due to the increased fluid and blood volume of pregnancy.

FIGURE 22.1 Perineal hematoma. Note the bulging swollen mass.

Nursing Management When excessive bleeding is encountered, initial management steps are aimed at improving uterine tone with immediate fundal massage, intravenous fluid resuscitation, and administration of uterotonic medications. If these methods fail to control bleeding, additional resources are mobilized and more aggressive interventions such as bimanual compression, internal uterine packing, and/or balloon tamponade techniques are employed by the health care provider. Other potential causes of bleeding should be thoroughly explored, and laboratory tests such as a complete blood count, type and cross-match, and coagulations studies should be obtained immediately. Transfusion of blood products should be instituted without hesitation once estimates of bleeding reach 1,500 mL (Nagtalon-Ramos, 2014). Concept Mastery Alert Priority Intervention for Uterine Atony Before initiating fundal massage, the nurse must first place a hand over the symphysis pubis to anchor the uterus and prevent possible uterine inversion.

Clearly, in all cases of unexpected hemorrhage, the interventions discussed as follows must be performed without delay. Postpartum hemorrhage is best managed by using a stepwise progressive approach. Manual message and pharmacologic therapies are first-line treatments. If the bleeding continues, second-line interventions might include the use of intrauterine balloon (or gauze) tamponade and uterine compression sutures. If these second-line therapies still don’t stop the bleeding, women may need to undergo radiologic embolization, pelvic devascularization, or hysterectomy. Peripartum hysterectomy remains the last-resort lifesaving measure and carries with it a higher mortality rate compared with nonobstetric hysterectomy. It is a most demanding obstetric surgery performed under very trying circumstances of life-threatening hemorrhage (Van de Velde, Diez, & Varon, 2015). Moreover, high-volume transfusions are often required, and there are significant postsurgical morbidity

risks such as renal failure, hepatic failure, respiratory distress syndrome, coagulopathies, septicemia, tissue hypoxia, and pituitary necrosis (Sheehan syndrome) (Rong, Yuna, & Yan, 2014). Postpartum hemorrhage outcomes can be improved by thorough preparation, anticipating the risks of PPH, and coordinating consultants for interventional procedures if warranted. PPH is a serious complication of pregnancy that is often unanticipated. Even with prompt aggressive management, postpartum bleeding can quickly evolve into a life-threatening event. Perinatal nurses are often the first to observe significant postpartum bleeding and their prompt initial response and continued assessments are pivotal in the anticipation and coordination of necessary interventions. Multidisciplinary team support is critical because obstetric caregivers need a full array of medical and surgical strategies to manage intractable bleeding. Because all postpartum women are at risk for hemorrhage, nurses need to possess the knowledge and skills to practice active management of the third stage of labor to prevent hemorrhage and to recognize, assess, and respond rapidly to excessive blood loss in their clients.

Massage the Uterus Massage the uterus if uterine atony is noted. The uterine muscles are sensitive to touch; massage stimulates the muscle fibers to contract. Massage the boggy uterus to stimulate contractions and expression of any accumulated blood clots while supporting the lower uterine segment. As blood pools in the vagina, stasis of blood causes clots to form. These clots need to be expelled as pressure is placed on the fundus. Note, however, that overly forceful massage can tire the uterine muscles, resulting in further uterine atony and increased pain. See Nursing Procedure 22.1 for the steps in massaging the fundus.

Administer a Uterotonic Drug Administer a uterotonic drug if repeated fundal massage and expression of clots fail; medication is probably needed to contract the uterus in order to control bleeding from the placental site. The injection of a uterotonic drug immediately after birth is an important intervention used to prevent PPH. Oxytocin (Pitocin); a synthetic analog of prostaglandin E1, misoprostol (Cytotec) or dinoprostone (Prostin E2); methylergonovine maleate (Methergine); and a derivative of prostaglandin (PGF2α), carboprost (Hemabate), are drugs used to manage postpartum hemorrhage (Drug Guide 22.1). However, misoprostol is not

approved by the U.S. Food and Drug Administration (FDA) for this purpose. The choice of which uterotonic drug to use for management of bleeding depends on the judgment of the health care provider, the availability of drugs, and the risks and benefits of the drug. All nurses need to be aware of the contraindications of administering each of the medications used to control postpartum hemorrhage as follows: • Pitocin–never give undiluted as a bolus injection intravenously

NURSING PROCEDURE 22.1

Massaging the Fundus Purpose: To Promote Uterine Contraction 1. After explaining the procedure to the woman, place one gloved hand on the area above the symphysis pubis (this helps to support the lower uterine segment). 2. Place the other gloved hand (usually the dominant hand) on the fundus. 3. With the hand on the fundus, gently massage the fundus in a circular manner. Be careful not to over massage the fundus, which could lead to muscle fatigue and uterine relaxation. 4. Assess for uterine firmness (uterine tissue responds quickly to touch). 5. If firm, apply gentle yet firm pressure in a downward motion toward the vagina to express any clots that may have accumulated. 6. Do not attempt to express clots until the fundus is firm because the application of firm pressure on an uncontracted uterus could cause uterine inversion, leading to massive hemorrhage. 7. Assist the woman with perineal care and applying a new perineal pad. 8. Remove gloves and wash hands.

DRUG GUIDE 22.1 DRUGS USED TO CONTROL POSTPARTUM HEMORRHAGE

• Cytotec–allergy, active cardiovascular disease, pulmonary or hepatic disease • Prostin E2–active cardiac, pulmonary, renal, or hepatic disease • Methergine–if the woman is hypertensive, do not administer

• Hemabate–contraindicated with asthma due to risk of bronchial spasm Remember Joan, the woman described at the beginning of the chapter? The nurse assesses her and finds that her uterus is boggy. What would the nurse do next? What additional nursing measures might be used if Joan’s fundus remains boggy? When should the health care provider be notified?

Maintain the Primary Intravenous Infusion Maintain the primary intravenous infusion and be prepared to start a second infusion at another site if blood transfusions are necessary. Draw blood for type and cross-match and send it to the laboratory. Administer oxytocics as ordered, correlating and titrating the infusion rate to assessment findings of uterine firmness and lochia. Assess for visible vaginal bleeding, and count or weigh perineal pads.

Take Note! Postpartum hemorrhage outcomes can be improved by thorough preparation, anticipating the risks factors of PPH in every woman admitted, and coordinating consultants for interventional procedures if warranted.

Check Vital Signs Check vital signs every 15 to 30 minutes, depending on the acuity of the mother’s health status. Monitor her complete blood count to identify any deficit or assess the adequacy of replacement. Assess the woman’s level of consciousness to determine changes that may result from inadequate cerebral perfusion. A Foley catheter is typically in place to keep the bladder empty to avoid displacement of her uterus. A fundus above the umbilicus and deviated laterally indicates a full bladder and interferes with uterine contractions to slow the bleeding.

Prepare the Woman for Removal of Retained Placental Fragments

Prepare the woman for removal of retained placental fragments. These fragments usually are manually separated and removed by the health care provider. Be sure that the health care provider remains long enough after birth to assess the bleeding status of the woman and determine the etiology. Assist the health care provider with suturing any lacerations immediately to control hemorrhage and repair the tissue. Nurses should anticipate and prepare the woman for transfer to the operating room for surgical intervention if tamponade techniques fail to achieve hemostasis. The blood bank should be notified that additional transfusions may be required and the woman’s condition closely monitored for signs of hypovolemic shock.

Continually Assess the Woman for Signs and Symptoms of Hemorrhagic Shock Continually assess the woman for signs and symptoms of hemorrhagic shock, a condition in which inadequate perfusion of organs results in insufficient availability of oxygen to satisfy the metabolic needs of the tissues (Green, 2016). Hemorrhagic shock is the most common form of shock encountered in obstetric practice. Subsequently, a catabolic state develops, leading to inflammation, endothelial dysfunction, and disruption of normal metabolic processes in vital organs. Once these events become established, the process of shock is often irreversible, even if volume and red blood cell deficits are corrected. The main goals of treatment of hemorrhagic shock include fluid resuscitation, correction of the imbalance between oxygen delivery and consumption, and treating DIC (Tanczos, Nemeth, & Molnar, 2015). A postpartum hemorrhage is a traumatic experience because medical complications are unexpected during what is anticipated as a joyful time. Assess the anxiety level of the woman; the woman going into hypovolemic shock is highly anxious and may lose consciousness. The woman’s significant others experience a high level of anxiety as well and need a great deal of support. Monitor the woman’s blood pressure, pulse, capillary refill, mental status, and urinary output. These assessments allow estimation of the severity of blood loss and help direct treatment. If the woman develops hemorrhagic shock, interventions focus on controlling the source of blood loss; restoring adequate oxygen-carrying capacity; and maintaining adequate tissue perfusion. Successful treatment depends on efficient collaboration among all health care team

members to meet the woman’s specific needs. For the woman with ITP, expect to administer glucocorticoids, intravenous immunoglobulin, intravenous anti-RhoD, and platelet transfusions. Prepare the woman for a splenectomy if the bleeding tissues do not respond to medical management. Be alert for women with abnormal bleeding tendencies, ensuring that they receive proper diagnosis and treatment. Teach them how to prevent severe hemorrhage by learning how to feel for and massage their fundus when boggy, assisting the nurse to keep track of the number of and amount of bleeding on perineal pads, and avoiding any medications with antiplatelet activity such as aspirin, antihistamines, or nonsteroidal anti-inflammatory drugs (NSAIDs).

Institute Emergency Measures If DIC Develops If the woman develops DIC, institute emergency measures to control bleeding and impending shock and prepare to transfer her to the intensive care unit. Identification of the underlying condition and elimination of the causative factor are essential to correct the coagulation problem. Be ready to replace fluid volume, administer blood component therapy, and optimize the mother’s oxygenation and perfusion status to ensure adequate cardiac output and endorgan perfusion. Continually reassess the woman’s coagulation status via laboratory studies. Monitor vital signs closely, being alert for changes that signal an increase in bleeding or impending shock. Observe for early signs of ecchymosis, including spontaneous bleeding from gums or nose, petechiae, excessive bleeding from the cesarean incision site or intravenous site, hematuria, and blood in the stool. Late signs include progressive changes in vital signs, skin color, and reduction of urinary output. Collectively, these findings correlate with decreased blood volume, decreased organ and peripheral tissue perfusion, and clots in the microcirculation (Levi & Schmaier, 2015).

Take Note! Always remember the five causes of postpartum hemorrhage and the appropriate intervention for each: (1) uterine atony—massage and oxytocics; (2) retained placental tissue—evacuation and oxytocics; (3) lacerations or hematoma— surgical repair; (4) thrombin (bleeding disorders)—blood products; and (5) uterine inversion caused by too much cord traction—gentle replacement of

uterus and oxytocics. Institute measures to avoid tissue trauma or injury, such as giving injections and drawing blood. Also provide emotional support to the client and her family throughout this critical time by being readily available and providing explanations and reassurance.

Preventing Postpartum Hemorrhage Avoid an episiotomy unless an emergency birth is necessary and the perineum is a limiting factor. It is important to have the continuous intrapartum presence of an experienced labor and birth nurse. Provide active management of the third stage of labor, including administration of a uterotonic medication after birth of anterior shoulder, controlled and gentle cord traction to deliver the placenta, and uterine massage after the placenta is out. Authors of a Cochrane review concluded that active management of the third stage of labor is associated with reduced blood loss, reduced risk of PPH, and a reduced prolonged third stage of labor (Mousa et al., 2014). Frequent staff education and PPH drills will help keep skills up to date. Nurses must identify and correct anemia and screen for coagulopathies before labor and birth. After birth, it is important to inspect the placenta (once it is delivered) for completeness. Assess woman for lower genital tract lacerations immediately after birth and reevaluate the woman’s vital signs and vaginal flow after childbirth. Finally, it is important to be aware of the mother’s beliefs about blood transfusions. Recently a workgroup representing all major women’s health professional organizations developed an obstetric hemorrhage safety bundle for practice to improve PPH outcomes. Some of their selected readiness action domains include: • Having a hemorrhage cart with supplies and instruction cards on every OB unit • Having immediate access to medications used to treat a massive hemorrhage • Establishing a response team within the hospital that can be called • Developing emergency-release transfusion protocols in the blood bank • Educating all staff on protocols and holding unit-based drills frequently (Main et al., 2015). In summary, careful monitoring of the mother’s vital signs, laboratory tests (in

particular, coagulation testing) and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality. Nurses must always be prepared to identify signs and symptoms of PPH, recognize maternal compromise and deal with hemorrhage promptly. By identifying hemorrhage promptly and providing swift interventions, maternal mortality and morbidity can be reduced. An intravenous oxytocin infusion is started for Joan. What assessments will need to be done frequently to make sure Joan is not losing too much blood? What discharge instructions need to be reinforced with Joan?

VENOUS THROMBOEMBOLIC CONDITIONS Venous thromboembolism is one of the leading causes of maternal mortality and morbidity with an annual incidence of one per 1,000 pregnancies, a ten times higher risk than the nonpregnant population (Testa et al., 2015). A thrombosis (blood clot within a blood vessel) can cause an inflammation of the blood vessel lining (thrombophlebitis), which in turn can lead to a thromboembolism (obstruction of a blood vessel by a blood clot carried by the circulation from the site of origin). Thrombi can involve the superficial or deep veins in the legs or pelvis. Superficial venous thrombosis usually involves the saphenous venous system and is confined to the lower leg. Superficial thrombophlebitis may be caused by the use of the lithotomy position during birth. Deep venous thrombosis (DVT) can involve deep veins from the foot to the calf, to the thighs, or pelvis. In both locations, thrombi can dislodge and migrate to the lungs, causing a pulmonary embolism (PE). DVT is a common condition that can have serious complications. Deep venous thrombi have a high probability of propagating and leading to pulmonary emboli, which may cause chest pain, breathlessness, and sudden death. Thus, an accurate and timely diagnosis of DVT is imperative. Although DVT is often clinically silent, it may present with a number of signs, including calf pain, edema, and venous distention. The three most common venous thromboembolic conditions occurring during the postpartum period are superficial venous thrombosis, DVT, and PE. Although venous thromboembolic disorders occur in less than 1% of all postpartum women, pulmonary embolus can be fatal if a clot obstructs the lung circulation; thus, early identification and treatment are paramount. Risk for postpartum venous thromboembolism is highest during the first three weeks after childbirth. Women with obstetric complications are at highest risk for this, and this risk remains elevated throughout the first twelve weeks postpartum (Tepper et al., 2014).

Pathophysiology Thrombus (blood clot) formation typically results from venous stasis, injury to the innermost layer of the blood vessel, and hypercoagulation. Venous stasis and hypercoagulation are both common in the postpartum period. If a clot dislodges and travels to the pulmonary circulation, PE can occur. PE is a potentially fatal condition that occurs when the pulmonary artery is blocked by a blood clot that has traveled from another vein into the lungs, causing an obstruction and infarction. When the clot is large enough to block one or more of the pulmonary vessels that supply the lungs, it can result in sudden death. Approximately 600,000 PEs occur yearly in the United States, resulting in 60,000 to 100,000 deaths (CDC, 2015b). Only 25% of all clients with PE are actually diagnosed, indicating that thousands of PEs go undetected. Many deaths due to PE are unrecognized and the diagnosis is often made at autopsy. PE is the leading cause of pregnancy-related death in the United States, occurring in 2 out of 100,000 live births. It most commonly occurs up to 3 weeks postpartum and following a surgical birth (Conti, et al., 2014). A national review of severe obstetric complications found a significant increase in the rate of PE associated with the increasing rate of cesarean births. Adequate treatment of thrombotic events in pregnancy is important to prevent progression of thrombosis to the development of pulmonary embolism (Sucker & Zotz, 2015).

Nursing Assessment Assess the woman closely for risk factors and signs and symptoms of thrombophlebitis. Look for risk factors in the woman’s history such as use of oral contraceptives before the pregnancy, smoking, employment that necessitates prolonged standing, history of thrombosis, thrombophlebitis, or endometritis, or evidence of current varicosities. Also look for other factors that can increase a woman’s risk, such as prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34 years), and multiparity. The likelihood of thrombophlebitis is increased through most of pregnancy and for approximately 12 weeks after childbirth. This is partly due to increased platelet stickiness and partly due to reduced fibrinolytic activity (Guimicheva, Czuprynska, & Arya, 2015). Ask the woman if she has pain or tenderness in the lower extremities. Suspect superficial venous thrombosis in a woman with varicose veins who reports tenderness and discomfort over the site of the thrombosis, most commonly in the calf area. The area appears reddened along the vein and is warm to the touch. The woman will report increased pain in the affected leg when she ambulates and bears weight. Manifestations of DVT are often absent and diffuse. If present, they are caused by an inflammatory process and obstruction of venous return. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted. A positive Homans’ sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by a strained muscle, contusion, clients with herniated intervertebral discs, calf muscle spasm, neurogenic leg pain, ruptured Baker’s cyst, and cellulitis (Heffline & Schmidt, 2014). Be alert for signs and symptoms of pulmonary embolism, including unexplained sudden onset of shortness of breath and severe chest pain. The woman may be apprehensive and diaphoretic. Additional manifestations may include tachypnea, tachycardia, hypotension, syncope, distention of the jugular vein, decreased oxygen saturation (shown by pulse oximetry), cardiac arrhythmias, hemoptysis, and a sudden change in mental status as a result of hypoxemia (Quellette, Harrington, & Kamangar, 2015). Prepare the woman for a

lung scan to confirm the diagnosis.

Nursing Management Nursing management focuses on preventing thrombotic conditions, promoting adequate circulation if thrombosis occurs, and educating the client about preventive measures, anticoagulant therapy, and danger signs.

Preventing Thrombotic Conditions Prevention of thrombotic conditions is an essential aspect of nursing management and can be achieved with the routine use of simple measures: • Developing public awareness about risk factors, symptoms, and preventive measures • Preventing venous stasis by encouraging activity that causes leg muscles to contract and promotes venous return (leg exercises and walking) • Dorsi/plantar flexion of feet with prolonged sitting to promote venous return • Using intermittent sequential compression devices to produce passive leg muscle contractions until the woman is ambulatory • Elevating the woman’s legs above her heart level to promote venous return • Stopping smoking to reduce or prevent vascular vasoconstriction • Applying compression stockings and removing them daily for inspection of legs • Using postoperative deep-breathing exercises to improve venous return by relieving the negative thoracic pressure on leg veins • Reducing hypercoagulability with the use of aspirin or anticoagulation therapy • Preventing venous pooling by avoiding pillows under knees, not crossing legs for long periods, and not leaving legs up in stirrups for long periods • Padding stirrups to reduce pressure against the popliteal angle • Avoiding sitting or standing in one position for prolonged periods • Avoiding trauma to legs to prevent injury to the vein wall • Increasing fluid intake to prevent dehydration • Avoiding the use of oral contraceptives In women at risk, early ambulation is the easiest and most cost-effective

method. Use of compression stockings decreases distal calf vein thrombosis by decreasing venous stasis and augmenting venous return (Wells, Forgie, & Rodger, 2014). Women who are at a high risk for thromboembolic disease based on risk factors or a previous history of DVT or PE may be placed on prophylactic anticoagulation therapy during pregnancy. A low-molecular-weight heparin such as enoxaparin (Lovenox) can be given or rivaroxaban (Xarelto), apixaban (Eliquis), or dabigatran etexilate (Pradaxa) can be given (Middeldorp, 2015). It is typically discontinued during labor and birth and then restarted during the postpartum period.

Promoting Adequate Circulation The mainstay of venous thromboembolic conditions is anticoagulation, while interventions such as thrombolysis and inferior vena cava filters are reserved for limited circumstances. For the woman with superficial venous thrombosis, administer NSAIDs for analgesia, provide for rest and elevation of the affected leg, apply warm compresses to the affected area to promote healing, and use antiembolism stockings to promote circulation to the extremities. Implement bed rest or limited ambulation if ordered and elevation of the affected extremity for the woman with DVT. These actions help to reduce interstitial swelling and promote venous return from that leg. Apply antiembolism stockings to both extremities as ordered. Fit the stockings correctly to avoid excess pressure and constriction and urge the woman to wear them at all times. Sequential compression devices can also be used for women with varicose veins, a history of thrombophlebitis, or a surgical birth. Anticoagulant therapy using a continuous intravenous infusion of low molecular-weight heparin along with vitamin K antagonists usually is initiated to prolong the clotting time and prevent extension of the thrombosis. Monitor the woman’s coagulation studies closely; these might include activated partial thromboplastin time (aPTT), whole-blood partial thromboplastin time, and platelet levels. A therapeutic aPTT value typically ranges from 35 to 45 seconds, depending on which standard values are used (Pagana, Pagana, & Pagana, 2014). Also apply warm moist compresses to the affected leg and administer analgesics as ordered to decrease the discomfort. After several days of intravenous low molecular-weight heparin therapy, expect to begin oral anticoagulant therapy as ordered. In most cases, the woman will continue to take this medication for several months after discharge.

For the woman who develops a pulmonary embolism, institute emergency measures immediately. The objectives of treatment are to prevent growth or multiplication of thrombi in the lower extremities, prevent more thrombi from traveling to the pulmonary vascular system, and provide cardiopulmonary support if needed. Administer oxygen via mask or cannula as ordered and initiate intravenous low molecular-weight heparin therapy titrated according to the results of the coagulation studies. Maintain the client on bed rest, and administer analgesics as ordered for pain relief. Be prepared to assist with administering thrombolytic agents, such as alteplase (tPA), which might be used to dissolve pulmonary emboli and the source of the thrombus in the pelvis or deep leg veins, thus reducing the potential for a recurrence.

Educating the Client Provide teaching about the use of anticoagulant therapy and danger signs that should be reported (Teaching Guidelines 22.1). Provide anticipatory guidance, support, and education about associated signs of complications and risks.

Teaching Guidelines 22.1

TEACHING TO PREVENT BLEEDING RELATED TO ANTICOAGULANT THERAPY • Watch for possible signs of bleeding and notify your health care provider if any occur: • Nosebleeds • Bleeding from the gums or mouth • Black tarry stools • Brown “coffee grounds” vomitus • Red to brown speckled mucus from a cough • Oozing at incision, episiotomy site, cut, or scrape • Pink, red, or brown-tinged urine • Bruises, “black and blue marks”

• Increased lochia discharge (from present level) • Practice measures to reduce your risk of bleeding: • Brush your teeth gently using a soft toothbrush. • Use an electric razor for shaving. • Avoid activities that could lead to injury, scrapes, bruising, or cuts. • Do not use any over-the-counter products containing aspirin or aspirin-like derivatives. • Avoid consuming alcohol. • Inform other health care providers about the use of anticoagulants, especially dentists. • Be sure to comply with follow-up laboratory testing as scheduled. • If you accidentally cut or scrape yourself, apply firm direct pressure to the site for 5 to 10 minutes. Do the same after receiving any injections or having blood specimens drawn. • Wear an identification bracelet or band that indicates that you are taking an anticoagulant. • Elimination of modifiable risk factors for DVT (smoking, use of oral contraceptives, a sedentary lifestyle, and obesity). • Importance of using compression stockings. • Avoidance of constrictive clothing and prolonged standing or sitting in a motionless, leg-dependent position. • Danger signs and symptoms (sudden onset of chest pain, dyspnea, and tachypnea) to report to the health care provider.

POSTPARTUM INFECTION Infection during the postpartum period is a common cause of maternal morbidity and mortality. Overall, postpartum infection is estimated to occur in up to 8% of all births and accounts for 15% of global maternal mortality. There is a higher occurrence in cesarean births than in vaginal births (Mattson & Smith, 2016). Postpartum infection is defined as a fever of 100.4° F (38° C) or higher after the first 24 hours after childbirth, occurring on at least 2 of the first 10 days after birth, exclusive of the first 24 hours (Dalton & Castillo, 2014). Risk factors include surgical birth, prolonged rupture of membranes, long labor with multiple vaginal examinations, inadequate hand hygiene, internal fetal monitoring, uterine manipulation, chorioamnionitis, instrumental birth, obesity, untreated infection prior to birth, retained placental fragments, obesity, gestational diabetes, extremes of client age, low socioeconomic status, and anemia during pregnancy (Jordan et al., 2014). Infections can easily enter the female genital tract externally and ascend through the internal genital structures. Postpartum women possess an increased risk for infection due to tissue trauma during birth, vulnerability from placenta separation site, and the incision from cesarean section. In addition, the normal physiologic changes of childbirth increase the risk of infection by decreasing the vaginal acidity due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. Postpartum infections usually arise from organisms that constitute the normal vaginal flora, typically a mix of aerobic and anaerobic species. Generally, they are polymicrobial and involve the following microorganisms: Staphylococcus aureus, Escherichia coli, Klebsiella, Gardnerella vaginalis, gonococci, coliform bacteria, group A or B hemolytic streptococci, Chlamydia trachomatis, and the anaerobes that are common to bacterial vaginosis. Prevention can be achieved by screening and treating vaginal colonization during pregnancy (Callahan, 2016). Common postpartum infections include metritis, surgical site infections, urinary tract infections, and mastitis.

Metritis Although usually referred to clinically as endometritis, postpartum uterine infections typically involve more than just the endometrial lining. Metritis is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus. Extension of metritis can result in parametritis, which involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic thrombophlebitis, which results when the infection spreads along venous routes into the pelvis. It occurs within the first two days postpartum or as late as two to six weeks postpartum (King et al., 2015). The uterine cavity is sterile until rupture of the amniotic sac. As a consequence of labor, birth, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus. In most cases, the bacteria responsible for pelvic infections are those that normally reside in the bowel, vagina, perineum, and cervix, such as E. coli, Klebsiella pneumoniae, or G. vaginalis. The risk of metritis increases dramatically after a cesarean birth; it complicates from 10% to 20% of cesarean births. This is typically an extension of chorioamnionitis that was present before birth (indeed, that may have been why the cesarean birth was performed). In addition, trauma to the tissues and a break in the skin (incision) provide entrances for bacteria to enter the body and multiply. ACOG (2014b) recommends use of one dose of prophylactic antibiotic therapy administered one hour before any cesarean section and this has become standard practice in the United States today. Once rupture of the amniotic membranes occurs during labor and birth, the uterus becomes more susceptible to colonization and infection, especially if it is a prolonged labor. Any area traumatized during childbirth is susceptible to infection.

Surgical Site Infections Any break in the skin or mucous membranes provides a portal for bacteria. In the postpartum woman, sites of wound infection include cesarean surgical incisions, the episiotomy site in the perineum, and genital tract lacerations (Fig. 22.2). Wound infections are usually not identified until the woman has been discharged from the hospital because symptoms may not show up until 24 to 48 hours after birth.

Urinary Tract Infections Urinary tract infections are most commonly caused by bacteria often found in bowel flora, including E. coli, Klebsiella, Proteus, and Enterobacter species. Invasive manipulation of the urethra (e.g., urinary catheterization), frequent vaginal examinations, and genital trauma increase the likelihood of a urinary tract infection. It is the most common cause of a fever in the postpartum woman.

Mastitis Mastitis is defined as inflammation of the mammary gland. A common problem that may occur within the first 2 days to 2 weeks postpartum. An estimated 5% of breast-feeding women develop lactational mastitis (Spiliopoulos & Mastrogiannis, 2014). Risk factors associated with mastitis include stasis of milk due to infrequent, inconsistent breastfeeding, and nipple trauma. As well as causing significant discomfort, it is a frequent reason for women to stop breastfeeding. It can result from any event that creates milk stasis: insufficient drainage of the breast, rapid weaning, oversupply of milk, pressure on the breast from a poorly fitting bra, a blocked duct, missed feedings, and breakdown of the nipple via fissures, cracks, or blisters (Nagtalon-Ramos, 2014). The most common infecting organism is S. aureus, which comes from the breast-feeding infant’s mouth or throat. Staphylococcus albus, E. coli, and streptococci are also causative agents, but found less frequently. Infection can be transmitted from the lactiferous ducts to a secreting lobule, from a nipple fissure to periductal lymphatics, or by circulation (Amir, 2014) (Fig. 22.3). A breast abscess may develop if mastitis is not treated adequately. Flu-like symptoms are often the first symptoms experienced by the mother. Breasts are red, tender, and hot to the touch. The upper, outer quadrant of the breast is the most common site for mastitis to occur because most of the breast tissue is located there with both the right and left breasts being equally affected. Effective milk removal, pain medication, and antibiotic therapy have been the mainstays of treatment.

Therapeutic Management METRITIS When metritis occurs, broad-spectrum antibiotics are used to treat the infection. Management also includes measures to restore and promote fluid and electrolyte balance, provide analgesia, and provide emotional support. In most treated women, fever drops and symptoms cease within 48 to 72 hours after the start of antibiotic therapy.

FIGURE 22.2 Postpartum wound infections. A. Infected episiotomy site. B. Infected cesarean birth incision.

FIGURE 22.3 With mastitis, an area on one breast is tender, hot, red, and painful.

SURGICAL SITE INFECTIONS Management for surgical site infections involves recognition of the infection, followed by opening of the wound to allow drainage. Aseptic wound

management with sterile gloves and frequent dressing changes if applicable, good hand hygiene, frequent perineal pad changes, hydration, and ambulation to prevent venous stasis and improve circulation are initiated to prevent development of a more serious infection or spread of the infection to adjacent structures. Parenteral antibiotics are the mainstay of treatment. Analgesics are also important, because women often experience discomfort at the wound site. URINARY TRACT INFECTIONS Urinary tract infections are common during the postpartum period and could be prevented by timely removal of urinary catheters used during labor or surgical births. Risk factors include catheterization, epidural anesthesia, and vaginal procedures. If the woman develops a urinary tract infection, fluids are used to treat dehydration. General nutrition measures include acidifying the urine by taking large doses of vitamin C or a regular intake of cranberry juice. Cranberry juice contains a substance with biologic activity that inhibits the growth of E. coli in the urinary tract (Wong & Rosh, 2015). Antibiotics may also be ordered if appropriate. MASTITIS Treatment of mastitis focuses on two areas: emptying the breasts and controlling the infection. Frequent breast emptying helps both infectious and noninfectious mastitis. The breast can be emptied either by the infant sucking or by manual expression. Increasing the frequency of nursing is advised. Lactation need not be suppressed. Control of infection is achieved with antibiotics. In addition, ice or warm packs and analgesics may be needed. In addition to antibiotics, management of lactational breast infections includes symptomatic treatment, assessment of the infant’s attachment to the breast, and reassurance, emotional support, education, and support for ongoing breast-feeding.

Take Note! Regardless of the etiology of mastitis, the focus is on reversing milk stasis, maintaining milk supply, and continuing breast-feeding, along with providing maternal comfort and preventing recurrence.

Nursing Assessment Perinatal nurses are the primary caregivers for postpartum women and have a unique opportunity to identify subtle changes that place women at risk for infection. Nurses play a key role in identifying signs and symptoms that suggest a postpartum infection. Today women are commonly discharged 24 to 48 hours after giving birth. Therefore, nurses must assess new mothers for risk factors and identify early, subtle signs and symptoms of an infectious process. Factors that place a woman at risk for a PPI are highlighted in Box 22.1. Review the client’s history and physical examination and labor and birth record for factors that might increase her risk for developing an infection. Then complete the assessment (using the “BUBBLE-EE” parameters discussed in Chapter 16), paying particular attention to areas such as the abdomen and fundus, breasts, urinary tract, episiotomy, lacerations, or incisions and being alert for signs and symptoms of infection (Table 22.3).

Take Note! A PPI is commonly associated with an elevated temperature, as mentioned previously. Other generalized signs and symptoms may include chills, foulsmelling vaginal discharge, headache, malaise, restlessness, anxiety, and tachycardia. In addition, the woman may have specific signs and symptoms based on the type and location of the infection. The acronym REEDA is frequently used for assessing a woman’s perineum status. It is derived from five components that have been identified to be associated with the healing process of the perineum. These include: 1. Redness—area may also feel warm to touch 2. Edema—may indicate infection or a hematoma 3. Ecchymosis—may indicate vaginal trauma 4. Discharge—should follow the expected lochia pattern 5. Approximation of skin edges— should be well aligned without gaps Each category is assessed and a number assigned (0 to 3 points) for a total REEDA score ranging from 0 to 15. The higher scores indicate increased tissue

trauma (Kaur et al., 2015). See Figure 22.4 for the REEDA method for assessing perineum healing.

BOX 22.1 FACTORS PLACING A WOMAN AT RISK FOR POSTPARTUM INFECTION • Prolonged (>18 to 24 hours) premature rupture of membranes (removes the barrier of amniotic fluid so bacteria can ascend) • Cesarean birth (allows bacterial entry due to break in protective skin barrier) • Urinary catheterization (could allow entry of bacteria into bladder due to break in aseptic technique) • Regional anesthesia that decreases perception of need to void (causes urinary stasis and increases risk of urinary tract infection) • Staff attending to woman are ill (promotes droplet infection from personnel) • Compromised health status, such as anemia, obesity, smoking, drug abuse (reduces the body’s immune system and decreases ability to fight infection) • Pre-existing colonization of lower genital tract with bacterial vaginosis, Chlamydia trachomatis, group B streptococci, S. aureus, and E. coli (allows microbes to ascend) • Retained placental fragments (provides medium for bacterial growth) • Manual removal of a retained placenta (causes trauma to the lining of the uterus and thus opens up sites for bacterial invasion) • Insertion of fetal scalp electrode or intrauterine pressure catheters for internal fetal monitoring during labor (provides entry into uterine cavity) • Instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk of trauma to genital tract, which provides bacteria access to grow) • Trauma to the genital tract, such as episiotomy or lacerations (provides a portal of entry for bacteria) • Prolonged labor with frequent vaginal examinations to check progress (allows time for bacteria to multiply and increases potential exposure to microorganisms or trauma) • Poor nutritional status (reduces body’s ability to repair tissue)

• Gestational diabetes (decreases body’s healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth) • Break in aseptic technique during surgery or birthing process (allows entry of bacteria) Adapted from Salam, R. A., Mansoor, T., Mallick, D., Lassi, Z. S., Das, J. K., & Bhutta, Z. A. (2014). Essential childbirth and postnatal interventions for improved maternal and neonatal health. Reproductive Health, 11(Suppl 1), S3–20; Jordan, R. G., Engstrom, J. L., Marfell, J. A., & Farley, C. L. (2014). Prenatal and postnatal care: A woman-centered approach. Ames, Iowa: Wiley Blackwell; and Wong, A. W., & Rosh, A. J. (2015). Postpartum infections. eMedicine. Retrieved from http://emedicine.medscape.com/article/796892-overview

Monitor the woman’s vital signs, especially her temperature. Changes may also signal an infection. TABLE 22.3 SIGNS AND SYMPTOMS OF POSTPARTUM INFECTIONS

Nursing Management Nursing management focuses on preventing postpartum infections. Use the following guidelines to reduce the incidence of postpartum infections: • Maintain aseptic technique when performing invasive procedures such as urinary catheterization, when changing dressings, and during all surgical procedures.

FIGURE 22.4 REEDA method for assessing perineum healing. Adapted from Davidson, N. (1974). REEDA: Evaluating postpartum healing. Journal of Nurse Midwifery 19(2), 6–8; and Nikpour, M.,

Shirvani, M. A., Azadbakht, M., Zanjani, R., & Mousavi, E. (2014). The effect of honey gel on abdominal wound healing in cesarean section: A triple blind randomized clinical trial. Oman Medical Journal, 29(4), 255–259.

• Use good hand hygiene technique before and after each client care activity. • Reinforce measures for maintaining good perineal hygiene. • Practice standard precautions whenever in contact with blood, body fluids, and excretions. • Use adequate lighting and turn the client to the side to assess the episiotomy site. • Use extreme caution when handling sharp instruments, specimens, and waste disposal. • Screen all visitors for any signs of active infections to reduce the client’s risk of exposure. • Review the client’s history for pre-existing infections or chronic conditions. • Monitor vital signs and laboratory results for any abnormal values. • Monitor the frequency of vaginal examinations and length of labor. • Assess frequently for early signs of infection, especially fever and the appearance of lochia. • Inspect wounds frequently for inflammation and drainage. • Encourage rest, adequate hydration, and healthy eating habits. • Reinforce preventive measures during any interaction with the client. If the woman develops an infection, review treatment measures, such as antibiotic therapy if ordered, and any special care measures, such as dressing changes, that might be needed (Nursing Care Plan 22.1). Postpartum women should be offered advice on the signs and symptoms of life-threatening conditions, including sepsis. Information should include the importance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell. Client teaching is a priority due to today’s short lengths of stay after childbirth. Some infections may not manifest until after discharge. Review the signs and symptoms of infection, emphasizing the danger signs that need to be reported to the health care provider. Most importantly, stress proper hand hygiene, especially after perineal care and before

and after breast-feeding. Also reinforce measures to promote breast-feeding, including proper breast care (see Chapter 16). Teaching Guidelines 22.2 highlights the major teaching points for a woman with a postpartum infection.

Teaching Guidelines 22.2

TEACHING FOR THE WOMAN WITH A POSTPARTUM INFECTION • Continue your antibiotic therapy as prescribed. • Take the medication exactly as ordered and continue with the medication until it is finished. • Do not stop taking the medication even when you are feeling better. • Check your temperature every day and call your health care provider if it is above 100.4° F (38° C). • Watch for other signs and symptoms of infection, such as chills, increased abdominal pain, change in the color or odor of your lochia, or increased redness, warmth, swelling, or drainage from a wound site such as your cesarean incision or episiotomy. Report any of these to your health care provider immediately. • Practice good infection prevention: • Always wash your hands thoroughly before and after eating, using the bathroom, touching your perineal area, or providing care for your newborn. • Wipe from front to back after using the bathroom. • Remove your perineal pad using a front-to-back motion. Fold the pad in half so that the inner sides of the pad that were touching your body are against each other. Wrap in toilet tissue or place in a plastic bag and discard. • Wash your hands before applying a new pad. • Apply a new perineal pad using a front-to-back motion. Handle the pad by the edges (top and bottom or sides) and avoid touching the inner aspect of the pad that will be against your body. • When performing perineal care with a peribottle, angle the spray of water to

that it flows from front to back. • Drink plenty of fluids each day and eat a variety of foods that are high in vitamins, iron, and protein. • Be sure to get adequate rest at night and periodically throughout the day.

POSTPARTUM AFFECTIVE DISORDERS The postpartum period involves extraordinary physiologic, psychological, and sociocultural changes in the life of a woman and her family. It is an exhilarating time for most women, but for others it may not be what they had expected. Women have varied reactions to their childbearing experiences, exhibiting a wide range of emotions. Typically, the delivery of a newborn is associated with positive feelings such as happiness, joy, and gratitude for the birth of a healthy infant. However, women may also feel weepy, overwhelmed, or unsure of what is happening to them. They may experience fear about loss of control; they may feel scared, alone, or guilty, or as if they have somehow failed. During the postpartum period, up to 85% of women experience some type of mood disorder (Joy, Mattingly, & Templeton, 2015). Postpartum affective disorders have been documented for years, but only recently have they received medical attention. Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. Reproductive hormones influence every biologic system and many women are particularly sensitive to the effects of perinatal changes in hormone levels after childbirth. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the chance for developing a mood disorder (Schiller, Meltzer-Brody, & Rubinow, 2015).

NURSING CARE PLAN 22.1 Overview of the Woman with a Postpartum Complication Jennifer, a 16-year-old G1P1, gave birth to a boy 3 days ago. It was a cesarean birth due to cephalopelvic disproportion following 25 hours of labor with ruptured membranes. Her temperature is 102.6° F (39.2° C). She is complaining of chills and malaise and says, “My incision really hurts.” Jennifer rates her pain as 7 to 8 out of 10. The incision site is red, swollen, and very warm to the touch. A 5-cm area of purulent drainage is noted on the dressing; a 3-cm area of the incision is slightly opened, with the wound edges separated. Jennifer’s lochia is scant and dark red, with a strong odor. She asks the nurse to take her baby back to the nursery because she doesn’t feel well enough to care for him. NURSING DIAGNOSIS: Ineffective thermoregulation related to bacterial invasion as evidenced by fever, complaints of chills and malaise, and statement of not feeling well Outcome Identification and Evaluation The client will exhibit a return to normothermia as evidenced by a body temperature being maintained below 99° F (37.2° C), reports of a decrease in chills and malaise, and statements of feeling better. Interventions: Promoting Fever Reduction • Assess vital signs every 2 to 4 hours and record results to monitor progress of infection. • Administer antipyretics as ordered to reduce temperature and help combat infection. • Encourage fluid intake to promote fluid balance. • Document intake and output to assess hydration status. • Offer cool bed bath or shower to reduce temperature. • Place cool cloth on forehead and/or back of neck to provide comfort. • Change bed linen and gown when damp from diaphoresis to provide comfort and hygiene.

NURSING DIAGNOSIS: Impaired skin integrity related to wound infection as evidenced by purulent drainage, redness, swelling, and separation of wound edges Outcome Identification and Evaluation The client will experience a resolution of wound infection as evidenced by a reduction in redness, swelling, and drainage from wound; absence of purulent drainage; and beginning signs and symptoms of wound healing. Interventions: Promoting Wound Healing • Administer antibiotic therapy as ordered to treat infection. • Perform frequent dressing changes and wound care as ordered to promote wound healing; monitor dressing for drainage, including amount, color, and characteristics, to evaluate for resolution of infection. • Use aseptic technique to prevent spread of infection. • Encourage fluid intake to maintain fluid balance; encourage adequate dietary intake, including protein, to promote healing. NURSING DIAGNOSIS: Acute pain related to infectious process Outcome Identification and Evaluation The client will report a decrease in pain as evidenced by pain rating of 0 or 1 on pain scale, verbalization of relief with pain management, and statements of feeling better and ability to rest comfortably. Interventions: Relieving Pain • Place client in semi-Fowler’s position to facilitate drainage and relieve pressure. • Assess pain level on pain scale of 0 to 10 to quantify pain level; reassess pain level after intervening to determine effectiveness of intervention. • Assess fundus gently to ensure appropriate involution. • Administer analgesics as needed and on time as ordered to maintain pain relief. • Provide for rest periods to allow for healing. • Assist with positioning in bed with pillows to promote comfort. • Offer nonpharmacologic pain measures such as a backrub to ease aches and

discomfort if desired and enhance effectiveness of analgesics. NURSING DIAGNOSIS: Risk for impaired parent–infant attachment related to effects of postpartum infection as evidenced by mother’s request to take baby back to the nursery Outcome Identification and Evaluation The client will begin to bond with newborn appropriately with each exposure as evidenced by desire to spend time with newborn, expression of positive feelings toward newborn when holding him, increasing participation in care of newborn as client’s condition improves, and statements about help and support at home to care for self and newborn. Interventions: Promoting Mother–Newborn Interaction • Promote adequate rest and sleep to ensure adequate energy for interaction and wound healing. • Bring newborn to mother after she is rested and has had an analgesic to allow mother to focus her energies on the child. • Progressively allow the client to care for her infant or comfort him as her energy level and pain level improve to promote self-confidence in caring for the newborn. • Offer praise and positive reinforcement for caretaking tasks; stress positive attributes of newborn to mother while caring for him to facilitate bonding and attachment. • Contact family members to participate in care of the newborn to allow mother to rest and recover from infection. • Encourage mother to care for herself first and then the newborn to ensure adequate energy for newborn’s care. • Arrange for assistance and support after discharge from hospital to provide necessary backup. • Refer to community health nurse for follow-up care of mother and newborn at home to foster continued development of maternal–infant relationship. Many types of affective disorders occur in the postpartum period. Although their description and classification may be controversial, the disorders are commonly classified on the basis of their severity as postpartum or baby blues,

postpartum depression, and postpartum psychosis.

Postpartum Blues Many postpartum women (approximately 80%) experience the “blues” (Callahan, 2016). The woman experiences rapid cycling mood symptoms during the first postpartum week typically. The woman exhibits mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, despondency, feelings of being overwhelmed, difficulty thinking clearly, and fatigue (Pop et al., 2015). Emotional lability is the most prominent symptom of the maternity blues. The “blues” typically peak on postpartum days 4 and 5 and usually resolve by postpartum day 10. Biologic, psychological, and social factors have been hypothesized as relevant to blues causation, but no studies have validated this. Although the woman’s symptoms may be distressing, they do not reflect psychopathology and usually do not affect the mother’s ability to function and care for her infant. Baby blues are usually self-limiting and require no formal treatment other than reassurance and validation of the woman’s experience, as well as assistance in caring for herself and the newborn. However, follow-up of women with postpartum blues is important; because up to 20% go on to develop postpartum depression (Alexander et al., 2014).

Postpartum Depression Depression is more prevalent in women than in men, which may be related to biologic, hormonal, and psychosocial factors. Postpartum depression (PPD) is a form of clinical depression that can affect women, and less frequently men, after childbirth. It affects as many as 20% of all mothers in the United States, and as many as 60% of adolescent mothers (ACOG, 2014c; CDC,2015c; Joy et al., 2015). Unlike the postpartum blues, women with postpartum depression feel worse over time, and changes in mood and behavior do not go away on their own. Postpartum depression may persist for a minimum of six months if untreated. Different from the baby blues, the symptoms of PPD last longer, are more severe, and require treatment. Some signs and symptoms of PPD include feeling the following: • Restless • Worthless • Guilty • Hopeless • Moody • Sad • Overwhelmed • Loss of enjoyment • Low energy level • Loss of libido The new mother may also: • Cry a lot • Exhibit a lack of energy and motivation • Be unable to make decisions or focus • Lose her memory • Experience a lack of pleasure • Have changes in, sleep, or weight • Show a lack of concern for herself

• Withdraw from friends and family • Have pains in her body that do not subside • Feel negatively toward her baby • Appetite disturbances • Feelings of isolation from others • Lack interest in her baby • Worry about hurting the baby • Act detached toward others and infant • Have recurrent thoughts of suicide and death (Bobo & Yawn, 2014). Postpartum depression affects not only the woman but also the entire family. Identifying depression early can substantially improve the client and family outcomes. PPD usually has a gradual onset and becomes evident within the first 6 weeks postpartum. The cause of PPD is not known, but research suggests that it is multifactorial. According to ACOG (2014c), “postpartum depression is likely to result from body, mind, and lifestyle factors combined.” The levels of estrogen, progesterone, serotonin, and thyroid hormone decrease sharply and return to normal during the immediate postpartum period, which can trigger depression and can change a woman’s mood and behavior. Other aspects that can lead to PPD include: • Unresolved feelings about the pregnancy • Fatigue after delivery from lack of sleep or broken sleep • Feelings of being less attractive • Inadequate assistance from partner • Lack of social support network • History of sexual or physical abuse • Unemployment or financial insecurity • Doubts about the ability to be a good mother • Stress from changes in work and home routines • Loss of freedom and old identity (Finley & Brizendine, 2015). PPD may lend itself to prophylactic intervention because its onset is

predictable, the risk period for illness is well defined, and women at high risk potentially could be identified using a screening tool. This is not the case for all women, however (see Evidence-Based Practice 22.1). Prophylaxis starts with a prenatal risk assessment and education. Based on the woman’s history of prior depression, prophylactic antidepressant therapy may be needed during the third trimester or immediately after giving birth. Management mirrors that of any major depression: a combination of antidepressant medication, antianxiety medication, adequate sleep and rest, and psychotherapy in an outpatient or inpatient setting (Callahan, 2016). Marital counseling may be necessary if marital problems are contributing to the woman’s depressive symptoms. The significant other’s or partner’s emotional health should not be overlooked during the woman’s pregnancy and throughout the first postpartum year. PPD, once expected only in new mothers, occurs in new significant others or partners as well. Up to 50% of significant others or partners whose partners suffer from PPD also have depressive symptoms, and little is known about the impact of maternal PPD on them. Depressive symptoms are likely to decrease their ability to provide maternal support. Significant other’s or partner’s PPD can be difficult to identify. New partners or significant others may seem more angry and anxious than sad, yet depression is present. When left untreated, partner’s PPD limits the significant other’s or partner’s capacity to provide emotional support to their partners and children. The highest rates of depression among fathers have been reported between 3 and 6 months postpartum. Factors that increase the risk of paternal PPD include a personal history of depression and/or anxiety, a low level of marital satisfaction, excessive financial stressors, a lack of significant other or partner’s parental leave, and the feeling that there is a great discrepancy between one’s expectations of parenthood and its realities (Feeley et al., 2015).

EVIDENCE-BASED PRACTICE 22.1 A SYSTEMATIC REVIEW OF THE RELATIONSHIP BETWEEN POSTPARTUM SLEEP DISTURBANCE AND POSTPARTUM DEPRESSION

STUDY Sleep is closely associated with psychological well-being. Insufficient sleep leads to adverse medical and psychological consequences and a poorer quality of life. Despite commonly held beliefs of joy and happiness, women are vulnerable to mood disorders during the postpartum period. Nighttime feedings and frequent nocturnal awakenings contribute to sleep maternal disturbances. Poor and fragmented sleep patterns are associated with a poor quality of life, a decrease in attentiveness and general well-being. More importantly, it may be a risk factor for postpartum depression. Postpartum depression has been linked with a series of psychosocial sequelae for mothers and their newborns. The purpose of this review was to analyze the relationship between postpartum sleep disturbance and postpartum depression.

Findings A systematic review was conducted on thirteen observational studies which included 3,793 women. The findings from all thirteen studies revealed a consistent strong relationship between sleep disturbance and postpartum depression. Short sleep duration and insomnia are related to a range of impaired functional outcomes that may negatively impact the daily life of postpartum women and their newborns.

Nursing Implications Based on this evidence, nurses can counsel postpartum women about the importance of getting adequate sleep when they are discharged and the link between sleep disturbances to postpartum depression. Nurses can suggest several interventions to assist the new mother in obtaining adequate sleep such as bathing the newborn at night before bedtime, asking for help from family to assist in nighttime diaper changes, and taking naps throughout the day when the newborn sleeps. These simple helpful interventions may be a valuable prevention measure to assist in increasing the mother’s wellness and reduce the risk of postpartum depression. Adapted from Bhati, S., & Richards, K. (2015). A systematic review of the relationship between postpartum sleep disturbance and postpartum depression. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(3), 350–357.

Assessing partner’s PPD is not easy. Nevertheless, it is important for all nurses who have contact with new partners to remain open to the notion that new partners are predisposed to PPD, particularly if their partner is afflicted. Delving deeper into understanding behaviors of withdrawing, indecisiveness, cynicism, avoiding, drinking, using drugs, fighting, partner violence, extramarital affairs, and feelings of heightened irritation will reveal important insights. Asking new partners candidly if they are feeling depressed, anxious, or angry can open the door to further exploration of these emotions (Weissman, 2014). Although partner depression is only now beginning to be defined and measured, sufficient evidence exists to warrant nurses’ attention and concern. Nurses may be most able to help a new partner devastated by PPD when they plant seeds of awareness that the disorder exists, that they are not alone, and that help is available. Despite the negative outcomes associated with PPD, rates of diagnosis and treatment are low mainly because of lack of recognition by the health care provider. In addition, PPD is the most misinterpreted, frequently dismissed, and most undiagnosed postpartum complication. Early recognition of PPD can eliminate the length of time that women and men have to suffer with this debilitating condition and can decrease the potentially harmful effects on the

infants involved. Screening for symptoms of PPD in both men and women is an important preliminary step to diagnosis and treatment, but the effectiveness of depression screening is dependent on the reliability and validity of the screening instruments in the population. Both the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Predictor Scale (PDSS) have been used to screen mothers for PPD, but it is not clear which instrument best predicts a diagnosis of postpartum depression (Thombs et al., 2014). The EPDS is a self-report, quick, and easy screening tool for PPD that consists of 10 questions with four possible responses. The couple fill out the tool according to their symptoms during the past 7 days, with each response given a score of 0 to 3 points, creating a maximum score of 30. Using a cutoff score of 9 or 10, the sensitivity is 86%; the specificity, 78%; and positive predictive value, 73% (Zhao et al., 2015). The PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual domains: 1. Anxiety/insecurity 2. Sleep/eating disturbance 3. Emotional liability 4. Loss of self-esteem 5. Guilt/shame 6. Cognitive impairment 7. Suicidal thoughts The scores range from 35 to 175. The scale has five symptoms for each domain, and the woman is asked to identify her degree of disagreement or agreement on the basis of her feelings over the past 2 weeks. The sensitivity of the PDSS is 91%; the specificity is 72% for detecting PPD. The PDSS takes 5 to 10 minutes to administer and is used during the postpartum period (King et al., 2015). Early identification, screening, prevention, and treatment of PPD are crucial for improving overall outcomes for the mother and infant, as well as for decreasing mortality and morbidity. This is why it is crucial for nurses to understand and know about the risk factors, signs and symptoms, prevention, and use and interpretation of screening tools and to make appropriate referrals

for treatment. Mass screening for PPD using a validated screening tool has been proven to improve the rates of detection and treatment of PPD and should be implemented in obstetricians’ and pediatricians’ offices and in primary care settings. The Edinburgh tool is shown in Figure 22.5.

Postpartum Psychosis At the severe end of the continuum of postpartum emotional disorders is postpartum psychosis, which occurs in 1 in 1000 live births (Doyle, Carballedo, & O’Keane, 2015). Postpartum psychosis, an emergency psychiatric condition, can result in a significant increased risk for suicide and infanticide. Symptoms of postpartum psychosis, such as mood lability, delusional beliefs, hallucinations, and disorganized thinking, can be frightening for the women who are affected and for their families. It generally surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt and worthlessness. Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations, extreme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, disorientation, depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself and the infant. The mother frequently loses touch with reality and experiences a severe regressive breakdown, associated with a high risk of suicide or infanticide (del Corral Serrano, 2015). Women with postpartum psychosis should not be left alone with their infants. Most women with postpartum psychosis are hospitalized for up to several months. Psychotropic drugs are almost always part of treatment, along with individual psychotherapy and support group therapy.

Take Note! The greatest hazard of postpartum psychosis is suicide. Infanticide and child abuse are also risks if the woman is left alone with her infant. Early recognition and prompt treatment of this disorder are imperative.

Nursing Assessment Postpartum affective disorders are often overlooked and go unrecognized despite the large percentage of women who experience them. The postpartum period is a time of increased vulnerability, but few women receive education about the possibility of depression after birth. In addition, many women may feel ashamed

of having negative emotions at a time when they “should” be happy; thus, they do not seek professional help. Nurses can play a major role in providing guidance about postpartum affective disorders, detecting manifestations, and assisting women to obtain appropriate care.

Consider This

Even though I was an assertive practicing attorney in my thirties, my first pregnancy was filled with nagging feelings of doubt about this upcoming event in my life. Throughout my pregnancy I was so busy with trial work that I never had time to really evaluate my feelings. I was always reading about the bodily changes that were taking place, and on one level I was feeling excited, but on another level I was emotionally drained. Shortly after the birth of my daughter, those suppressed nagging feelings of doubt surfaced big time and practically immobilized me. I felt exhausted all the time and was only too glad to have someone else care for my daughter. I didn’t breast-feed because I thought it would tie me down too much. Although at the time I thought this “low mood” was normal for all new mothers, I have since found out it was postpartum depression. How could any woman be depressed about this wondrous event? Thoughts: Now that postpartum depression has been “taken out of the closet” and recognized as a real emotional disorder, it can be treated. This woman showed tendencies during her pregnancy but was able to suppress the feelings and go forward. Her description of her depression is very typical of many women who suffer in silence, hoping to get over these feelings in time. What can nurses do to promote awareness of this disorder? Can it be prevented?

FIGURE 22.5 Adapted from Edinburgh Postnatal Depression Scale (EPDS). From Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786.

Begin the assessment by reviewing the history to identify general risk factors that could predispose a woman to depression: • Poor coping skills • First pregnancy • Low self-esteem • Numerous life stressors • History of abuse • Mood swings and emotional stress • Previous psychological problems or a family history of psychiatric disorders • Substance abuse • Limited or lack of social support network Also review the history for specific pregnancy and birth factors that may increase the woman’s risk for depression. These may include a history of PPD, evidence of depression during the pregnancy, prenatal anxiety, a difficult or complicated pregnancy, traumatic birth experience, or birth of a high-risk or special-needs infant (Callahan, 2016). Be alert for physical findings. Assess the woman’s activity level, including her level of fatigue. Ask about her sleeping habits, noting any problems with insomnia. When interacting with the woman, observe for verbal and nonverbal indicators of anxiety as well as her ability to concentrate during the interaction. Difficulty concentrating and anxious behaviors suggest a problem. Also assess her nutritional intake: weight loss due to poor food intake may be seen. Assessment can identify women with a high-risk profile for depression, and the nurse can educate them and make referrals for individual or family counseling if needed. Some common assessment findings associated with PPD are listed in Box 22.2.

Nursing Management Nurses need to educate themselves about this disorder to facilitate early recognition of signs and symptoms of it, which, in turn, would make early treatment possible, thus supporting recovery. Furthermore, greater knowledge could contribute to providing more effective and compassionate care to these women. Nursing management focuses on assisting any postpartum woman to

cope with the changes of this period. Encourage the client to verbalize what she is going through and emphasize the importance of keeping her expectations realistic. Assist the woman in structuring her day to regain a sense of control over the situation. Encourage her to seek help if necessary, using available support systems. Also reinforce the need for good nutrition and adequate exercise and sleep (Bobo & Yawn, 2014). The nurse can play an important role in assisting women and their partners with postpartum adjustment. Providing facts about the enormous changes that occur during the postpartum period is critical. This information would include changes in the woman’s body. Review the signs and symptoms of all three affective disorders. This information is typically included as part of prenatal visits and childbirth education classes. Know the risk factors associated with these disorders and review the history of clients and their families. Use specific, nonthreatening questions to aid in early detection, such as “Have you felt down, depressed, or hopeless lately?” and “Have you felt little interest or pleasure in doing things recently?”

BOX 22.2 COMMON ASSESSMENT FINDINGS ASSOCIATED WITH POSTPARTUM DEPRESSION • Loss of pleasure or interest in life • Low mood, especially in the morning, sadness, tearfulness • Exhaustion that is not relieved by sleep • Feelings of guilt • Weight loss • Low energy • Irritability • Poor personal hygiene • Constipated • Preoccupied and unfocused • Indecisiveness • Diminished concentration • Anxiety • Despair • Compulsive thoughts • Loss of libido • Loss of confidence • Sleep difficulties (insomnia) • Loss of appetite • Bleak and pessimistic view of the future • Not responding to infant’s cries or cues for attention • Social isolation, won’t answer the door or the phone • Feelings of failure as a mother Adapted from American College of Obstetrics and Gynecology [ACOG]. (2014c). Postpartum

depression. Retrieved from http://www.acog.org/Patients/FAQs/Postpartum-Depression#blues; Centers for Disease Control and Prevention [CDC]. (2015c). Depression among women of reproductive age. Retrieved from http://www.cdc.gov/reproductivehealth/depression/; and Joy, S., Mattingly, P. J., & Templeton, H. B. (2015). Postpartum depression: An overview of postpartum mood disorders. eMedicine. Retrieved from http://emedicine.medscape.com/article/271662-overview

Discuss factors that may increase a woman’s vulnerability to stress during the postpartum period, such as sleep deprivation and unrealistic expectations, so couples can understand and respond to those problems if they occur. Stress that many women need help after childbirth and that help is available from many sources, including people they already know. Assisting women to learn how to ask for help is important so they can gain the support they need. Also provide educational materials about postpartum emotional disorders. Have available referral sources for psychotherapy and support groups appropriate for women experiencing postpartum adjustment difficulties. See Evidence-Based Practice 22.1. KEY CONCEPTS Postpartum hemorrhage is a potentially life-threatening complication of both vaginal and cesarean births. It is the leading cause of maternal mortality in the United States. A good way to remember the causes of postpartum hemorrhage is the “5 Ts”: tone, tissue, trauma, thrombin, and traction. Uterine atony is the most common cause of early postpartum hemorrhage, which can lead to hypovolemic shock. Oxytocin (Pitocin), misoprostol (Cytotec), dinoprostone (Prostin E2), methylergonovine maleate (Methergine), and prostaglandin PGF2α (carboprost [Hemabate]) are commonly used drugs used to manage postpartum hemorrhage. Failure of the placenta to separate completely and be expelled interferes with the ability of the uterus to contract fully, thereby leading to hemorrhage. Causes of subinvolution include retained placental fragments, distended bladder, uterine myoma, and infection. Lacerations should always be suspected when the uterus is contracted and

bright-red blood continues to trickle out of the vagina. Conditions that cause coagulopathies may include idiopathic thrombocytopenic purpura, von Willebrand disease, and disseminated intravascular coagulation. Pulmonary embolism is a potentially fatal condition that occurs when the pulmonary artery is obstructed by a blood clot that has traveled from another vein into the lungs, causing obstruction and infarction. The major causes of a thrombus formation (blood clot) are venous stasis and hypercoagulation, both of which are common in the postpartum period. Postpartum infection is defined as a fever of 100.4° F (38° C) or higher after the first 24 hours after childbirth, occurring on at least 2 of the first 10 days exclusive of the first 24 hours. Common postpartum infections include metritis, wound infections, urinary tract infections, and mastitis. Postpartum emotional disorders are commonly classified on the basis of their severity: “baby blues,” postpartum depression, and postpartum psychosis. Management of postpartum depression mirrors the treatment of any major depression: a combination of antidepressant medication, antianxiety medication, and psychotherapy in an outpatient or inpatient setting.

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(12th ed.). St. Louis, MO: Mosby Elsevier. Pavord, S., & Maybury, H. (2015). How I treat postpartum hemorrhage. Blood, 125(18), 2759–2770. Pollak, E. S. (2015). von Willebrand disease. eMedicine. Retrieved from http://emedicine.medscape.com/article/206996-overview Pop, V. J., Truijens, S. E., Spek, V., Wijnen, H. A., van Son, M. J., & Bergink, V. (2015). A new concept of maternity blues: Is there a subgroup of women with rapid cycling mood symptoms?. Journal of Affective Disorders, 177, 74–79. Quellette, D. R., Harrington, A., & Kamangar, N. (2015). Pulmonary embolism. eMedicine. Retrieved from http://emedicine.medscape.com/article/300901-overview Rong, J., Yuna, G., & Yan, C. (2014). Risk factors associated with emergency peripartum hysterectomy. Chinese Medical Journal, 127(5), 900–904. Salam, R. A., Mansoor, T., Mallick, D., Lassi, Z. S., Das, J. K., & Bhutta, Z. A. (2014). Essential childbirth and postnatal interventions for improved maternal and neonatal health. Reproductive Health, 11(Suppl 1), S3--S20. Schiller, C. E., Meltzer-Brody, S., & Rubinow, D. R. (2015). The role of reproductive hormones in postpartum depression. CNS Spectrums, 20(1), 48–59. Shields, L. E., Wiesner, S., Fulton, J., & Pelletreau, B. (2015). Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. American Journal of Obstetrics and Gynecology, 212(3), 272–280. Silverman, M. A. (2015). Idiopathic thrombocytopenic purpura. eMedicine. Retrieved from http://emedicine.medscape.com/arti cle/ 779545-overview Skidmore-Roth, L. (2015). Mosby’s 2015 nursing drug reference (28th ed.). St. Louis, MO: Mosby Elsevier. Spiliopoulos, M., & Mastrogiannis, D. (2015). Normal and abnormal puerperium. eMedicine. Retrieved from http://emedicine.medscape.com/article/260187-overview#a1 Sucker, C., & Zotz, R. B. (2015). Prophylaxis and treatment of venous thrombosis and pulmonary embolism in pregnancy. Reviews in vascular medicine. doi:10.1016/j.rvm.2015.05.003 Tánczos, K., Németh, M., & Molnár, Z. (2015). What’s new in hemorrhagic shock?. Intensive Care Medicine, 41(4), 712–714. Tepper, N. K., Boulet, S. L., Whiteman, M. K., Monsour, M., Marchbanks, P. A., Hooper, W. C., et al. (2014). Postpartum venous thromboembolism: Incidence and risk factors. Obstetrics & Gynecology, 123(5), 987–996. Testa, S., Passamonti, S. M., Paoletti, O., Bucciarelli, P., Ronca, E., Riccardi, A., et al. (2015). The “Pregnancy Health-care Program” for the prevention of venous thromboembolism in pregnancy. Internal and Emergency Medicine, 10(2), 129–134. Thombs, B. D., Arthurs, E., Coronado-Montoya, S., Roseman, M., Delisle, V. C., Leavens, A., et al. (2014). Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. Journal of

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CHAPTER WORKSHEET MULTIPLE CHOICE QUESTIONS 1. A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. Call the client’s health care provider immediately. b. Immediately set up an intravenous infusion of magnesium sulfate. c. Assess the fundus and ask her about her voiding status.

d. Reassure the mother that this is a normal finding after childbirth. 2. A postpartum woman reports hearing voices and says, “The voices are telling me to do bad things to my baby.” The clinic nurse interprets these findings as suggesting postpartum: a. Psychosis b. Anxiety disorder c. Depression d. Blues 3. When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication? a. Deep venous thrombosis b. Postpartum psychosis c. Uterine infection d. Postpartum hemorrhage 4. Which of the following would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? a. Stop breast-feeding and apply lanolin b. Administer analgesics and bind both breasts c. Apply warm or cold compresses and administer analgesics d. Remove the nursing bra and expose the breast to fresh air 5. While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority? a. Assessing vital signs immediately b. Measuring her next urinary output c. Massaging her fundus d. Notifying the woman’s obstetrician 6. Methergine has been ordered for a postpartum woman because of excessive

bleeding. The nurse should question this order if which of the following is present? a. Mild abdominal cramping b. Tender inflamed breasts c. Pulse rate of 68 beats per minute d. Blood pressure of 158/96 mm Hg 7. Which of the following findings would lead the nurse to suspect that a woman is developing a postpartum complication? a. Moderate lochia rubra for the first 24 hours b. Clear lung sounds upon auscultation c. Temperature of 100° F d. Chest pain experienced when ambulating 8. Which of the following factors in a postpartum woman’s history would lead the nurse to monitor the woman closely for an infection? a. Hemoglobin of 12 mg/dL b. Manually extracted placenta c. Labor of 10 hours length d. Multiparity of 5 pregnancies

CRITICAL THINKING EXERCISES 1. Mrs. Griffin had a 22-hour labor before a cesarean birth. Her membranes ruptured 20 hours before she came to the hospital. Her fetus showed signs of fetal distress, so internal electronic fetal monitoring was used. Her most recent test results indicate she is anemic. a. What postpartum complication is this new mother at highest risk for? Why? b. What assessments need to be done to detect this complication? c. What nursing measures will the nurse use to prevent this complication? 2. Tammy, a 32-year-old G9P9, had a spontaneous vaginal birth 2 hours ago. Tammy has been having a baby each year for the past 9 years. Her lochia has been heavy, with some clots. She hasn’t been up to void since she had epidural

anesthesia and has decreased sensation to her legs. a. What factors place Tammy at risk for postpartum hemorrhage? b. What assessments are needed before planning interventions? c. What nursing actions are needed to prevent a postpartum hemorrhage? 3. Lucy, a 25-year-old G2P2, gave birth 2 days ago and is expected to be discharged today. She had severe postpartum depression 2 years ago with her first child. Lucy has not been out of bed for the past 24 hours, is not eating, and provides no care for herself or her newborn. Lucy states she already has a boy at home and not having a girl this time is disappointing. a. What factors/behaviors place Lucy at risk for an affective disorder? b. Which interventions might be appropriate at this time? c. What education does the family need prior to discharge?

STUDY ACTIVITIES 1. Compare and contrast postpartum blues, postpartum depression, and postpartum psychosis in terms of their features and medical management. 2. Visit and select a website from the Student Resources for Chapter 22. Critique the website regarding its helpfulness to parents, the correctness of the information, and when it was last updated. 3. Interview a woman who has given birth and ask if she had any complications and what was most helpful to her during the experience. 4. The number one cause of postpartum hemorrhage is ___________________. 5. When giving report to the nurse who will be caring for a woman and her newborn in the postpartum period, what information should the labor nurse convey?

BRINGING IT ALL TOGETHER: CASE STUDY Sheila is an 18-year-old G1P1 Hispanic who had her first child 2 days ago via primary cesarean section. Her pregnancy was uneventful, but she didn’t attend prenatal clinic very often. She presented to the hospital in labor at 39 weeks of

gestation with ruptured membranes. The client reported that her membranes had been ruptured for a “couple of days,” but she wasn’t really sure. Upon admission, she was dilated 2 cm/40% effacement. She labored for about 7 hours when the health care provider came in to check her. She was only 5 cm/completely effaced at that time. She was receiving IV antibiotics for her “prolonged rupture” status as per CDC guidelines. The health care provider inserted an internal fetal monitor with a scalp electrode and also an intrauterine pressure catheter because she was obese and the nurse was having difficulty in picking up the FHR tracing. She had no progress for the next four hours and the fetus was noted to develop tachycardia with a baseline heart rate increase to 170 bpm. A primary cesarean section was performed and she was given perioperative antibiotic prophylaxis at the time of surgery. Infant was LGA and Apgar scores were 9/9 at one minute and 5 minutes, respectively.

ASSESSMENT On day 1, as the nurse caring for this client, you obtain a set of postpartum vital signs: T—101.6, P—102, BP—110/80, R—18. Sheila appears pale and is diaphoretic. Her lochia rubra is of moderate amount and foul smelling. She complains of uterine tenderness when you palpate her fundus. Her surgical site is intact without redness or drainage. She states she didn’t have the breakfast that was served because she had no appetite. Her breasts are nontender and full upon palpation. She plans to bottle feed and has a supportive bra on. Sheila ambulates well and does her own peri-care. Go to

to find questions to consider about this case.

unit eight The Newborn at Risk

23 Nursing Care of the Newborn with Special Needs

KEY TERMS appropriate for gestational age asphyxia extremely low birth weight full term newborn large for gestational age (LGA) late preterm newborn low birth weight (LBW) post-term newborn preterm newborn

retinopathy of prematurity (ROP) small for gestational age (SGA) very low birth weight

Learning Objectives Upon completion of the chapter, you will be able to: 1. Examine factors that assist in identifying a newborn at risk due to variations in birth weight and gestational age. 2. Detect contributing factors and common complications associated with dysmature infants and their management. 3. Compare and contrast a small-for-gestational-age newborn and a large-forgestational-age newborn; a post-term and preterm newborn. 4. Differentiate associated conditions that affect the newborn with variations in birth weight and gestational age, including appropriate management. 5. Outline the nurse’s role in helping parents experiencing perinatal grief or loss. 6. Integrate knowledge of the risks associated with late preterm births into nursing interventions, discharge planning, and parent education. Anna and her husband were stunned when she went into labor at 7 months’ gestation. They couldn’t understand what would cause her to give birth early, but it happened. When they approached the neonatal intensive care unit (NICU), Anna took a deep breath and looked down at her tiny baby with tubes coming from everywhere. What feelings might they be experiencing at this moment?

Words of Wisdom Guiding a parent’s hand to touch a frail or ill newborn demonstrates courage and compassion under very difficult circumstances and is a powerful tool in helping

them to deal with the newborn’s special needs. Every family looks forward to the birth of a healthy newborn. Most newborns are born between 38 and 42 weeks’ gestation and weigh 6 to 8 pounds, but variations in birth weight or gestational age can occur, and newborns with these variations have special needs. Gestational age at birth is inversely correlated with the risk that the infant will experience physical, neurologic, or developmental sequelae (March of Dimes, 2015a). In some cases, however, unexpected difficulties and challenges occur along the way and some newborns are born very ill and need special advanced care to survive. Some complications are unexpected and occur without warning. Other times, there are risk factors that increase the risk of problems in newborns. When a woman gives birth to a newborn with problems involving immaturity or birth weight, especially one who is considered high risk, she may go through a grieving process in which she mourns the loss of the healthy full-term newborn she had expected. Through this process she learns to come to terms with the experience she now faces. The development of new technologies and regionalized care centers for the care of newborns with special needs has resulted in significant improvements. Nurses need to have a sound knowledge base to identify the newborn with special needs and to provide coordinated care. The key to identify a newborn with special needs related to birth weight or gestational age variation is an awareness of the factors that could place a newborn at risk. These factors are similar to those that would suggest a high-risk pregnancy. Being able to anticipate the birth of a newborn at risk allows the birth to take place at a health care facility equipped with the resources to meet the mother’s and newborn’s needs. This is important in reducing mortality and morbidity. Healthy People 2020 identifies preterm births and low birth weight as important national health goals (U.S. Department of Health and Human Services, 2010). (See Healthy People 2020 23.1.) This chapter discusses the nursing management of newborns with special needs related to variations in birth weight and gestational age. It also describes selected associated conditions affecting these newborns. Due to the frailty of these newborns, the care of the family experiencing perinatal loss and the role of the nurse in helping the family cope also are addressed.

BIRTH-WEIGHT VARIATIONS Fetal growth is influenced by maternal nutrition, genetics, placental function, environment, and a multitude of other factors. Assigning size to a newborn is a way to measure and monitor the growth and development of the newborn at birth. Newborns can be classified according to their weight and weeks of gestation. Knowing the group into which a newborn fits is important.

HEALTHY PEOPLE 2020 • 23.1

Appropriate for gestational age (AGA) characterizes approximately 80% of newborns and describes a newborn with a normal length, weight, head circumference, and body mass index (Panda, 2015). Being in the AGA group confers the lowest risk for any problems. These infants have lower morbidity and mortality than other groups. Small for gestational age (SGA) describes newborns who typically weigh less than 2,500 grams (5 lb 8 oz) at term due to less growth in utero than expected. A newborn is also classified as SGA if his or her birth weight is at or below the 10th percentile as correlated with the number of weeks of gestation on a growth chart. Large for gestational age (LGA) describes newborns whose birth weight is above the 90th percentile on a growth chart and who weigh more than 4,000 g (8 lb 13 oz) at term due to accelerated overgrowth for length of gestation (Sacks et al., 2015). The following terms describe other newborns with marginal weights at birth and of any gestational age: • Low birth weight: less than 2,500 g (5.5 lb) (Fig. 23.1) • Very low birth weight: less than 1,500 g (3 lb 5 oz) • Extremely low birth weight: less than 1,000 g (2 lb 3 oz)

Small-for-Gestational-Age Newborns Newborns are considered SGA when they weigh less than 2,500 g (5 lb 8 oz) or fall below the 10th percentile for length, weight, or head circumference on a growth chart for gestational age. These infants can be preterm, term, or postterm.

FIGURE 23.1 A low–birth-weight newborn in an isolette.

Concept Mastery Alert Planning Priority Care for the Small for Gestational Age Infant Infants who are small for gestational age (SGA) are different from preterm infants who often have underdeveloped respiratory systems. SGA infants often have developed respiratory systems, but need frequent observations for hypoglycemia because of inadequate glycogen stores. This leads to the need for frequent and early feedings.

In some SGA newborns, the rate of growth does not meet the expected growth pattern. Termed fetal growth restriction, these newborns also are considered at risk, with the perinatal morbidity and mortality rate increased substantially compared with that of the AGA newborn (Cunningham et al., 2014). Fetal

growth restriction is the pathologic counterpart of SGA. However, an important distinction to make between SGA and fetal growth restriction newborns is that not all who are SGA have growth restriction. The converse also is true: not all newborns who have fetal growth restriction are SGA. Some SGA newborns are constitutionally small; that is, they are statistically small but otherwise healthy. Historically, fetal growth restriction has been categorized as symmetric or asymmetric. Symmetric fetal growth restriction (an insult that occurs early at less than 28 weeks in the gestation) refers to fetuses with equally poor growth rates of the head, the abdomen, and the long bones. All parameters of growth are affected. Typically these infants have the poorest long-term prognosis and are never able to catch up in size when compared with unaffected children (Nagtalon-Ramos, 2014). Asymmetric fetal growth restriction (insult occurs late —at more than 28 weeks’ gestation) refers to infants whose head and long bones are spared compared with their abdomen and internal organs. The brain and heart are spared and are larger, but overall weight and organ sizes are reduced. Generally, the asymmetrical fetal growth restriction infant has a better prognosis than one who is symmetrically fetal growth restriction. Once the infant is born, optimal nutrition usually restores normal growth potential. The current belief is that in most cases fetal growth restriction is a continuum from symmetrical (early stages) to asymmetrical (late stages). There is a strong association between stillbirth and fetal growth restriction. Early detection and management of fetal growth restriction can lead to reduced morbidity and mortality. A recent study found that combined screening of maternal factors and biophysical profiles conducted at 30 to 34 weeks’ gestation can identify a large proportion of pregnancies that subsequently will have SGA newborns (Bakalis et al., 2015). Fetal growth is dependent on genetic, placental, and maternal factors. Cognitive and motor development during infancy forms the basis for children’s subsequent development. Newborns that experience nutritional deficiencies in utero and are born SGA are at risk for cognitive deficits that can undermine their academic performance throughout their lives. SGA infants are associated with increased neonatal morbidity and mortality as well as short stature, cardiovascular disease, insulin resistance, diabetes mellitus type 2, dyslipidemia, and end-stage renal disease in adulthood. In addition, SGA children have decreased levels of intelligence and cognition, although the effects are mostly subtle. The overall outcome of each child is the result of a complex interaction between intrauterine and extrauterine factors (Oros et al., 2014). The fetus is thought to have an inherent growth potential that, under normal

circumstances, yields a healthy newborn of appropriate size. The maternal– placental–fetal units act in harmony to meet the needs of the fetus during gestation. However, growth potential in the fetus can be limited, and this is analogous to failure to thrive in the infant. The causes of both can be intrinsic or environmental. Factors that can contribute to the birth of an SGA newborn are highlighted in Box 23.1.

Nursing Assessment Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as smoking, drug abuse, alcohol consumption, preeclampsia, anemia, uteroplacental insufficiency, intrauterine viral infection, cord prolapse, chronic maternal illness, hypertension, multiple gestation, or genetic disorders. This information allows the nurse to anticipate a possible problem and to be prepared to intervene quickly should one occur. At birth, perform a thorough physical examination, closely observing the newborn for typical characteristics, including: • Head disproportionately large compared with rest of body • Wasted appearance of extremities

BOX 23.1 POTENTIAL FACTORS CONTRIBUTING TO THE BIRTH OF SMALL-FOR-GESTATIONAL-AGE NEWBORNS

Maternal Causes • Chronic hypertension • Diabetes mellitus with vascular disease • Autoimmune diseases • Living at a high altitude (hypoxia) • Smoking or exposure to passive smoke • Periodontal disease of the mouth • Maternal age of 34 years old • Failure to seek any prenatal care • Substandard living conditions • Low socioeconomic status • Abuse and violence • Substance abuse (heroin, cocaine, methamphetamines) • Hemoglobinopathies (sickle cell anemia) • Preeclampsia • Exposure to occupational hazards • Chronic renal disease • Maternal nutrition (malnutrition or obesity) • Extreme maternal stress • TORCH group infections

Placental Factors • Abnormal cord insertion • Chronic abruption • Decreased surface area, infarction • Decreased placental weight • Placenta previa • Placental insufficiency

Fetal Factors • Trisomy 13, 18, and 21 • Turner’s syndrome • Chronic fetal infection (cytomegalovirus, rubella, syphilis, toxoplasmosis) • Congenital anomalies (heart, diaphragmatic hernia, tracheoesophageal fistula) • Radiation exposure • Multiple fetal gestation Adapted from Kenner, C., & Lott, J. W. (2015). Comprehensive neonatal care (5th ed.). New York, NY: Springer Publishing Company; Fanaroff, A. A., & Fanaroff, J. M. (2014). Klaus and Fanaroff’s care of the high-risk neonate (6th ed.) Philadelphia, PA: Elsevier; and Verklan, M. T., & Walden, M. (2014). Core curriculum for neonatal intensive care nursing (5th ed.). St. Louis, MO: Saunders Elsevier.

• Reduced subcutaneous fat stores • Jittery secondary to hypoglycemia • Temperature instability • Decreased amount of breast tissue • Scaphoid abdomen (sunken appearance) • Wide skull sutures secondary to inadequate bone growth • Poor muscle tone over buttocks and cheeks • Loose and dry skin that appears oversized • Thin umbilical cord Also assess the SGA newborn for any congenital malformations, neurologic insults, or indications of infection. SGA newborns commonly face problems after birth because of the decrease in placental function during gestation. Table 23.1 highlights some of the common problems associated with SGA newborns and others experiencing a variation in birth weight or gestational age. Anticipate the need for and provide resuscitation as indicated by the newborn’s condition.

Nursing Management Interventions for the SGA infant may include obtaining weight, length, and head circumference, comparing them with standards, and documenting the findings. Perform frequent serial blood glucose measurements as ordered and monitor vital signs, being particularly alert for changes in respiratory status that might indicate respiratory distress. Institute measures to maintain a neutral thermal environment to prevent cold stress and acidosis. Metabolic needs are increased for catch-up growth. Initiate early and frequent oral feedings unless contraindicated. At birth the newborn’s glucose level is approximately 70% of the mother’s serum glucose. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy (Chandran et al., 2015). Any newborn stressed at birth uses up available glucose stores with resulting hypoglycemia, a plasma glucose concentration at or below 40 mg/dL (Nagtalon-Ramos, 2014). With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through intermittent oral feedings. If oral feedings are not accepted, an intravenous infusion with 10% dextrose in water may be needed to maintain the glucose level above 40 mg/dL. Weigh the newborn daily and ensure that he or she has adequate rest periods to decrease metabolic requirements. Monitor feeding tolerance, sucking, and swallowing ability. POLYCYTHEMIA Polycythemia is not uncommon and is a potentially serious disorder of newborns. It is defined as a venous hematocrit above 65% and hemoglobin of more than 20 g. The hematocrit in a newborn peaks between 6 to 12 hours of age and decreases gradually after that. Polycythemia occurs in up to 12% of neonates, and occurs commonly in SGA newborns 6 to 12 hours after birth (Lessaris, 2015). The relationship between hematocrit and viscosity is almost linear until 65% and exponential thereafter. Increased viscosity of blood is associated with symptoms of hypoperfusion. Clinical features related to hyperviscosity may affect all organ systems. Hyperviscosity of blood results in increased resistance to blood flow and decreased oxygen delivery. In the newborn, hyperviscosity can cause abnormalities of central nervous system function, hypoglycemia, decreased renal function, cardiorespiratory distress, and coagulation disorders. Hyperviscosity has been reported to be associated with long-term motor and cognitive neurodevelopmental disorders (Fanaroff &

Fanaroff, 2014). SGA newborns, infants of mothers with diabetes, newborns with jaundice, and multiple births are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age (Alsafadi et al., 2014). TABLE 23.1 COMMON PROBLEMS ASSOCIATED WITH NEWBORNS EXPERIENCING A VARIATION IN BIRTH WEIGHT OR GESTATIONAL AGE

Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin, lethargy) and monitor blood results. Asymptomatic newborns with a hematocrit between 65% and 70% may simply be supported with fluids, close observation, and a repeat hematocrit level in 12 hours (Mahajan, Une, & Bansal, 2015). If the newborn is symptomatic, a partial exchange transfusion with replacement of removed red blood cell volume with volume expanders may be used, but this treatment is considered controversial and not validated by current evidence-based practice research. Provide anticipatory guidance to parents about any treatments and procedures that are being done. Emphasize the need for close follow-up and careful monitoring of the infant’s growth in length, weight, and head circumference and feeding patterns throughout the first year of life to confirm any “catch-up” growth taking place.

Large-for-Gestational-Age Newborns A newborn whose weight is above the 90th percentile on growth charts is defined as LGA. The range of weight is 4,000 to 5,000 g, or more than 9 lb. LGA infants may be preterm, term, or post-term. Based on these definitions, up to 10% of all births involve an LGA newborn. This large size can place the mother and fetus or newborn at risk for adverse outcomes (Creasy et al., 2014). Because of the newborn’s large size, vaginal birth may be difficult and occasionally results in birth injury. In addition, shoulder dystocia, clavicular fractures, and facial palsies are common. The incidence of cesarean births is very high with LGA newborns to avoid arrested labor and birth trauma.

Take Note! Maternal diabetes is commonly associated with LGA newborns. However, due to poor placental perfusion, the newborn may experience fetal growth restriction and be SGA.

Nursing Assessment Assessment of the LGA newborn begins with a review of the maternal history, which can provide clues as to whether the woman has an increased risk of giving birth to a LGA newborn. Maternal factors that increase the chance of bearing a LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, post-term gestation, maternal obesity, paternal height, gestational weight gain, male fetus, and genetics (Donnelley et al., 2014). At birth, assess the newborn for common characteristics. The typical LGA newborn has a large body and appears plump and full faced. The increase in body size is proportional. However, the head circumference and body length are in the upper limits of intrauterine growth. These newborns have poor motor skills and have difficulty regulating behavioral states. LGA newborns are more difficult to arouse to a quiet alert state (Neonatal Handbook, 2015a). Thoroughly assess the LGA newborn at birth to identify traumatic birth injuries such as fractured clavicles, brachial palsy, facial paralysis, phrenic nerve

palsy, skull fractures, or hematomas. Perform a neurologic examination to identify any nerve palsies, looking for abnormalities such as immobility of the upper arm. Observe and document any injuries discovered to allow for early intervention and improved outcomes. LGA infants are at risk for hypoglycemia related to early depletion of glycogen stores in the liver. Obtain frequent blood glucose levels as ordered to evaluate for hypoglycemia. The clinical signs are often subtle and include lethargy, apathy, drowsiness, irritability, tachypnea, weak crying, temperature instability, jitteriness, seizures, apnea, bradycardia, cyanosis or pallor, feeble sucking and poor feeding, hypotonia, and coma. Other disorders, including septicemia, severe respiratory distress, and congenital heart disease, may present with similar findings. In addition, be alert for other common problems, such as polycythemia and hyperbilirubinemia (see Table 23.1 earlier in this chapter).

Nursing Management Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. It is commonly associated with a variety of neonatal conditions like prematurity, fetal growth restriction, fetal growth restriction, and maternal diabetes. It may be asymptomatic in some newborns. Screening for hypoglycemia in high-risk LGA infants is essential. Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. LGA infants needing dextrose infusion rates above 12 mg/kg/min should be investigated for a definite cause of hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment are recommended (Mitanchez et al., 2015). Assist in stabilizing the LGA newborn. Monitor blood glucose levels within 30 minutes of birth and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia, regardless of age. To help prevent hypoglycemia, initiate feedings, which can be formula or breast milk, with intravenous glucose supplementation as needed. Monitor and record intake and output and obtain daily weights to aid in evaluating nutritional intake. Observe for signs of polycythemia and hyperbilirubinemia and report any immediately to the health care provider so that early interventions can be taken to prevent poor long-term neurologic development outcomes. Polycythemia and

hyperviscosity are associated with fine and gross motor delays, speech delays, and neurologic sequelae (Neonatal Handbook, 2015b). Increasing fluid volume aids in decreasing blood viscosity. Partial exchange transfusion with plasma or normal saline may be used to lower hematocrit and decrease blood viscosity, but this treatment remains controversial (Lessaris, 2015). Hydration, early feedings, and phototherapy are used to treat hyperbilirubinemia (see Chapter 24 for more information about hyperbilirubinemia). Provide parental guidance about the treatments and procedures being done and about the need for follow-up care for any abnormalities identified.

GESTATIONAL AGE VARIATIONS The mean duration of pregnancy, calculated from the first day of the last normal menstrual period, is approximately 280 days, or 40 weeks. Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn and one born after completion of 42 weeks is classified as a post-term newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. An additional classification has been added, the late preterm newborn (near term)—one who is born between 34 weeks and 36 weeks, 6 days of gestation. • Preterm newborn: before 37 completed weeks of gestation • Late preterm newborn (near term): 34 to 366/7 weeks • Full term newborn: 38 through 41 completed weeks of gestation • Post-term newborn: 42 weeks or more Precise knowledge of a newborn’s gestational age is imperative for effective postnatal management. Determination of gestational age by the nurse assists in planning appropriate care for the newborn and provides important information regarding potential problems that need interventions. See Chapter 18 for more information on assessing gestational age.

Take Note! Although preterm and post-term newborns may appear to be at opposite ends of the gestational age spectrum and are very different in size and appearance, both are at high risk and need special care.

Preterm Newborn A preterm newborn is one who is born before the completion of 37 weeks’ gestation. There has been improved survival of preterm infants due to the advancing technology and improved evidence-based perinatal care. Although the national birth rate has been declining since the 1990s, the preterm birth rate has been climbing rapidly. Approximately one in nine infants, or nearly half a million infants, is born before the 37th week of gestation (March of Dimes, 2015b). Prematurity is now the leading cause of death worldwide, and can cause long-term health problems for these infants throughout their lives and affect their education and ability to work. Prematurity costs society more than $26 billion annually and takes a high toll on families. The etiology of about 40% of all preterm births is unknown (March of Dimes, 2015c). Research suggests that four main etiologies may lead to spontaneous premature labor and birth: • Infections/inflammation. Studies suggest that premature labor is often triggered by the body’s natural immune response to certain bacterial infections, such as those involving the genital and urinary tracts and fetal membranes. Even infections far away from the reproductive organs, such as periodontal disease, may contribute to premature births. • Maternal or fetal stress. Chronic psychosocial stress in the mother or physical stress (such as insufficient blood flow from the placenta) in the fetus appears to result in production of a stress-related hormone called corticotropin-releasing hormone (CRH). CRH may stimulate production of a cascade of other hormones that trigger uterine contractions and premature birth. • Bleeding. The uterus may bleed because of problems such as placental abruption. Bleeding triggers the release of various proteins involved in blood clotting that also appear to stimulate uterine contractions. • Stretching. The uterus may become overstretched by the presence of two or more fetuses, excessive amounts of amniotic fluid, or uterine or placental abnormalities, leading to the release of chemicals that stimulate uterine contractions (March of Dimes, 2015d). Preterm births take an enormous financial toll, estimated to be in the billions of dollars. They also take an emotional toll on those involved.

Changes in perinatal care practices, including regional care, have reduced newborn mortality rates. Transporting high-risk pregnant women to a tertiary center for birth rather than transferring the neonate after birth is associated with a reduction in neonatal mortality and morbidity (Kaneko et al., 2015). Despite increasing survival rates, preterm infants continue to be at high risk for neurodevelopmental disorders such as cerebral palsy, intellectual disability, intraventricular hemorrhage, congenital anomalies, neurosensory impairment, behavioral problems, high frequency attention problems, psychiatric disorders, and chronic lung disease (Wilson-Costello & Payne, 2016). Making sure that all pregnant women receive quality prenatal care throughout pregnancy is a major method for preventing preterm births.

Effects of Prematurity on Body Systems Since the preterm newborn did not remain in utero long enough, every body system may be immature, affecting the newborn’s transition from intrauterine to extrauterine life and placing him or her at risk for complications. Without full development, organ systems are not capable of functioning at the level needed to maintain extrauterine homeostasis (Salam et al., 2014). Recall Anna, who was described at the beginning of the chapter; she gave birth to a newborn at 7 months’ gestation. What problems would you anticipate that her newborn might have? RESPIRATORY SYSTEM The respiratory system is one of the last body systems to mature. Therefore, the preterm newborn is at great risk for respiratory complications. A few of the problems that affect the preterm newborn’s breathing ability and adjustment to extrauterine life include: • Surfactant deficiency, leading to the development of respiratory distress syndrome • Unstable chest wall, leading to atelectasis • Immature respiratory control centers, leading to apnea • Smaller respiratory passages, leading to an increased risk for obstruction • Inability to clear fluid from passages, leading to transient tachypnea

CARDIOVASCULAR SYSTEM The preterm newborn has great difficulty making the transition from intrauterine to extrauterine life in terms of changing from a fetal to a newborn circulation pattern. Higher oxygen levels in the circulation once air breathing begins spur this transition. If the oxygen levels remain low secondary to perinatal asphyxia, the fetal pattern of circulation may persist, causing blood flow to bypass the lungs. Another problem affecting the cardiovascular system is the increased incidence of congenital anomalies associated with continued fetal circulation— patent ductus arteriosus and an open foramen ovale. In addition, impaired regulation of blood pressure in preterm newborns may cause fluctuations throughout the circulatory system. Of special note is cerebral blood flow, which may predispose the fragile blood vessels in the brain to rupture, causing intracranial hemorrhage (Fanaroff & Fanaroff, 2014). GASTROINTESTINAL SYSTEM Preterm newborns usually lack the neuromuscular coordination required to maintain the sucking, swallowing, and breathing regimen necessary for sufficient calorie and fluid intake to support growth. Perinatal hypoxia causes shunting of blood from the gut to more important organs such as the heart and brain. Subsequently, ischemia and damage to the intestinal wall can occur. This combination of shunting, ischemia, damage to the intestinal wall, and poor sucking ability places the preterm infant at risk for malnutrition and weight loss. In addition, preterm newborns have a small stomach capacity, weak abdominal muscles, compromised metabolic function, limited ability to digest proteins and absorb nutrients, and weak or absent suck and gag reflexes. All of these limitations place the preterm newborn at risk for nutritional deficiency and subsequent growth and development delays (Neonatal Handbook, 2015c). The preterm infant’s ability to coordinate sucking, swallowing, and breathing are challenged. As a result, preterm infants often require enteral or intravenous feeding. Enteral tube feeding will help to conserve energy even in an infant who is able to suck. The exact nutritional needs of preterm infants depend on their gestational age, postnatal age, weight, route of nutritional intake, growth rate, activity, and thermal environment. Preterm infants that are ill or experiencing stressful situations have higher energy requirements. Preterm infants take time to establish enteral intakes, and parenteral nutrition is now an integral component of care, but safe amounts of macronutrients, and the optimal amino acid and lipid composition remains an uncertainty (Embleton, Morgan, & King, 2015).

Currently, minimal enteral feeding is used to prepare the preterm newborn’s gut to overcome the many feeding difficulties associated with gastrointestinal immaturity. It involves the introduction of small amounts, usually 0.5 to 1 mL/kg/hr, of enteral feeding to induce surges in gut hormones that enhance maturation of the intestine. This minute amount of breast milk or formula given via gavage (tube) feeding prepares the gut to absorb future introduction of nutrients. It builds mucosal bulk, stimulates development of enzymes, enhances pancreatic function, stimulates maturation of gastrointestinal hormones, reduces gastrointestinal distention and malabsorption, and enhances transition to oral feedings (Koletzko, Poindexter, & Uauy, 2014). RENAL SYSTEM The renal system of the preterm newborn is immature, reducing the baby’s ability to concentrate urine and slowing the glomerular filtration rate. As a result, the risk for fluid retention, with subsequent fluid and electrolyte disturbances, increases. In addition, preterm newborns have limited ability to clear drugs from their systems, thereby increasing the risk of drug toxicity. Close monitoring of the preterm newborn’s acid–base and electrolyte balance is critical to identify metabolic inconsistencies. Prescribed medications require strict evaluation to prevent overwhelming the preterm baby’s immature renal system. IMMUNE SYSTEM The preterm newborn’s immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks’ gestation. This protection is lacking if the baby was born before this time. In addition, preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. Moreover, the preterm newborn’s thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Thus, anticipating and preventing infections is the goal; preventing infections has a better outcome than treating them. CENTRAL NERVOUS SYSTEM The preterm newborn is susceptible to injury and insult to the central nervous system, increasing the potential for long-term disability into adulthood. Like all

newborns, preterm newborns have difficulty with temperature regulation and maintaining stability. However, their risk for heat loss is compounded by inadequate amounts of insulating subcutaneous fat; lack of muscle tone and flexion to conserve heat; inadequate brown fat to generate heat; limited muscle mass activity, reducing the possibility of producing their own heat; inability to shiver to generate heat; and an immature temperature-regulating center in the brain (Kenner & Lott, 2014). It is crucial to prevent cold stress, which would increase the newborn’s metabolic and oxygen needs. The goal is to create a neutral thermal environment in which oxygen consumption is minimal but body temperature is maintained (Fanaroff & Fanaroff, 2014). In addition, the preterm newborn is especially susceptible to hypoglycemia due to immature glucose control mechanisms, decreased glucose stores, and a reduced availability of alternative fuels such as ketone bodies.

Take Note! Glucose is needed by the brain and central nervous system to maintain and support numerous body system functions.

Nursing Assessment Preterm newborns are at high risk for numerous problems and require special care. When preterm labor develops and cannot be stopped by medical interventions, plans are necessary for appropriate management of the mother and the preterm newborn, such as transporting them to a regional center with facilities to care for preterm newborns or notifying the facility’s NICU. Depending on the degree of prematurity, the preterm newborn may be kept in the NICU for months. A thorough assessment of the preterm newborn upon admission to the nursery provides a baseline from which to identify changes in clinical status. Be aware of the common physical characteristics and be able to identify any deviation from the expected (Fig. 23.2). Common physical characteristics of preterm infants may include: • Birth weight of less than 5.5 lb • Scrawny appearance • Head disproportionately larger than chest circumference

• Poor muscle tone • Minimal subcutaneous fat • Undescended testes in males • Prominent clitoris and labia minora in females • Plentiful lanugo (soft, downy hair), especially over the face and back • Poorly formed ear pinna, with soft, pliable cartilage • Fused eyelids • Soft and spongy skull bones, especially along suture lines • Matted scalp hair, woolly in appearance • Absent-to-a-few creases in the soles and palms • Minimal scrotal rugae in male infants; • Thin, transparent skin with visible veins • Breast and nipples not clearly delineated • Abundant vernix caseosa (Verklan & Walden, 2014). Be alert for evidence that might suggest that the preterm newborn is developing a complication (see Table 23.1). Review the maternal history to identify risk factors for preterm birth and check antepartum and intrapartum records for maternal infections to anticipate the need for treatment. Maternal risk factors associated with preterm birth include a previous preterm delivery, low socioeconomic status, preeclampsia, hypertension, poor maternal nutrition, smoking, multiple gestation, infection, advanced maternal age, and substance abuse. Assess the newborn’s gestational age and assess for fetal growth restriction if appropriate. Inspect the newborn’s skin closely, especially skin color. Assess vital signs, including temperature via skin probe to identify hypothermia or fever, and heart rate for tachycardia or bradycardia. Evaluate the newborn’s respiratory effort and respiratory rate. Observe for periods of apnea lasting longer than 20 seconds. Monitor oxygen saturation levels by pulse oximetry to validate perfusion status. Note and report any signs of respiratory distress. Auscultate lung and heart sounds, being especially alert for possible murmur, which would indicate the presence of patent ductus arteriosus in a preterm newborn. Assess neurologic status by observing the newborn’s behavior. Note any restlessness, hypotonia, or weak cry or sucking effort and report unusual

findings.

FIGURE 23.2 Characteristics of a preterm newborn. A. Few plantar creases. B. Soft, pliable ear cartilage, matted hair, and fused eyelids. C. Lax posture with poor muscle tone. D. Breast and nipple area barely visible. E. Male genitalia with minimal rugae on scrotum. F. Female genitalia with prominent labia and clitoris.

Monitor laboratory studies such as hemoglobin and hematocrit for signs of polycythemia. Screen for hypoglycemia upon admission and then hourly, always observing for nonspecific signs of hypoglycemia such as lethargy, poor feeding, and seizures. Evaluate serum bilirubin concentrations. Finally, assess the mother and family members. Identify family strengths and coping mechanisms to establish a basis for intervention.

Nursing Management During the past 50 years in the United States, the rising preterm birth rate, a progressive decrease in preterm mortality, and a lowering of the limit of viability have made preterm birth a significant public health problem. It is estimated that, each day throughout the world, over 40,000 infants are born prematurely. Preterm birth creates a crisis for the mother and family. Multiple studies have found that hospitalization for preterm newborns is often followed by negative mental health/behavioral outcomes, anxiety and depressive disorders, and longterm neurologic sequelae. Emerging evidence suggests that partners/significant others experience high rates of psychological stress in the first few months after a preterm birth (Treyvaud, 2014). Preterm newborns present with immaturity of all organ systems, abundant physiologic challenges, and significant morbidity and mortality globally (Salam et al., 2014). The nurse must be vigilant for complications when managing preterm newborns (Fig. 23.3 and Nursing Care Plan 23.1).

FIGURE 23.3 The physical condition of a preterm newborn demands skilled assessment and nursing care.

PROMOTING OXYGENATION Newborns normally start to breathe without assistance and often cry after birth, being stimulated by a change in pressure gradients and environmental temperature. The work of taking that first breath is primarily due to overcoming the surface tension of the walls of the terminal lung units at the gas–tissue interface. Subsequent breaths require less inspiratory pressure since there is an increase in functional capacity and air retained. By 1 minute of age, most newborns are breathing well. A newborn who fails to establish adequate, sustained respiration after birth is said to have asphyxia (perinatal acidosis), which is the deprivation of oxygen during the birth process, resulting in fetal hypoxia that can lead to organ damage. Asphyxia is the most common clinical insult in the perinatal period that results in brain injury, which may lead to intellectual disability, cerebral palsy, or seizures (Herrera-Marschitz et al., 2015). The preterm infant lacks surfactant. Surfactant lowers surface tension in the alveoli and stabilizes them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Therefore, preterm newborns develop atelectasis quickly without alveoli stabilization. The inability to initiate and establish respirations leads to hypoxemia and ultimately hypoxia (decreased oxygen), acidosis (decreased pH), and hypercarbia (increased carbon dioxide). This change in the

newborn’s biochemical environment may inhibit the transition to extrauterine circulation, thus allowing fetal circulation patterns to persist. Failure to initiate extrauterine breathing or failure to breathe well after birth leads to hypoxia (too little oxygen in the cells of the body). As a result, the heart rate falls, cyanosis develops, temperature decreases, blood pressure decreases, and respirations are altered (apnea, tachypnea, retractions, grunting, and nasal flaring) and the newborn becomes hypotonic and unresponsive. Although this can happen with any newborn, the risk is higher in preterm newborns. Prevention and early identification of at risk newborns are essential. Prenatal risk factors that can help identify the newborn that may need resuscitation at birth secondary to asphyxia include: • History of substance abuse • Gestational hypertension • Fetal distress due to hypoxia before birth • Chronic maternal diseases such as diabetes or a heart or renal condition • Maternal or perinatal infection • Placental problems (placenta previa or abruptio placentae) • Umbilical cord problems (nuchal or prolapsed) • Difficult or traumatic birth • Multiple births • Congenital heart disease • Maternal anesthesia or recent analgesia • Preterm or post-term birth (Neonatal Handbook, 2015d).

NURSING CARE PLAN 23.1 Overview of the Care of a Preterm Newborn Alice, an 18-year-old, felt that she had done everything right during her first pregnancy and certainly didn’t anticipate giving birth to a preterm newborn at 32 weeks’ gestation. When Mary Kaye was born, she had respiratory distress and hypoglycemia and couldn’t stabilize her temperature. Assessment revealed the following: newborn described as scrawny in appearance; skin thin and transparent with prominent veins over abdomen; hypotonia with lax, extended positioning; weak sucking reflex when nipple offered; respiratory distress with tachypnea (70 breaths/min), nasal flaring, and sternal retractions; low blood glucose level suggested by lethargy, tachycardia, jitteriness; axillary temperature of 96.8° F (36° C) despite warmed blanket; weight 2,146 g (4.73 lb); length 45 cm (17.72 in). NURSING DIAGNOSIS: Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, and sternal retractions Outcome Identification and Evaluation The newborn’s respiratory status will return to an adequate level of functioning as evidenced by rate remaining within 30 to 60 breaths/min, maintenance of acceptable oxygen saturation levels, and minimal to absent signs of respiratory distress. Interventions: Promoting Optimal Breathing Pattern • Assess gestational age and risk factors for respiratory distress to allow early detection. • Anticipate need for bag and mask setup and wall suction to allow for prompt intervention should respiratory status continue to worsen. • Assess respiratory effort (rate, character, effort) to identify changes. • Assess heart rate for tachycardia and auscultate heart sounds to determine worsening of condition. • Observe for cues (grunting, shallow respirations, tachypnea, apnea, tachycardia, central cyanosis, hypotonia, increased effort) to identify need

for additional oxygen. • Maintain slight head elevation to prevent upper airway obstruction. • Assess skin color to evaluate tissue perfusion. • Monitor oxygen saturation level via pulse oximetry to provide objective indication of perfusion status. • Provide supplemental oxygen as indicated and ordered to ensure adequate tissue oxygenation. • Assist with any ordered diagnostic tests, such as chest x-ray and arterial blood gases (ABGs), to determine effectiveness of treatments. • Cluster nursing activities to reduce oxygen consumption. • Maintain a neutral thermal environment to reduce oxygen consumption. • Monitor hydration status to prevent fluid volume deficit or overload. • Explain all events and procedures to the parents to help alleviate anxiety and promote understanding of the newborn’s condition. NURSING DIAGNOSIS: Ineffective thermoregulation related to lack of fat stores and hypotonia as evidenced by extended positioning, low axillary temperature despite warmed blanket, respiratory distress, and lethargy Outcome Identification and Evaluation The newborn will demonstrate ability to regulate temperature as evidenced by temperature remaining in normal range 97.7° to 99.5° F (36.5° to 37.5° C) and absent signs of cold stress. Interventions: Promoting Thermoregulation • Assess the axillary temperature every hour or use a thermistor probe to monitor for changes. • Review maternal history to identify risk factors contributing to problem. • Monitor vital signs, including heart rate and respiratory rate, every hour to identify deviations. • Check radiant heat source or isolette to ensure maintenance of appropriate temperature of the environment. • Assess environment for sources of heat loss or gain through evaporation, conduction, convection, or radiation to minimize risk of heat loss. • Avoid bathing and exposing newborn to prevent cold stress. • Warm all blankets and equipment that come in contact with newborn; place

warmed cap on the newborn’s head and keep it on to minimize heat loss. • Encourage kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth. • Educate parents on how to maintain a neutral thermal environment, including importance of keeping the newborn warm with a cap and doublewrapping with blankets and changing them frequently to keep dry to promote newborn’s adjustment. • Demonstrate ways to safeguard warmth and prevent heat loss. NURSING DIAGNOSIS: Risk for imbalanced nutrition: less than body requirements related to poor sucking and lack of glycogen stores necessary to meet the newborn’s increased metabolic demands as evidenced by weak sucking reflex, low birth weight, and signs and symptoms of hypoglycemia, including lethargy, tachycardia, and jitteriness Outcome Identification and Evaluation The newborn will demonstrate adequate nutritional intake, remaining free of signs of hypoglycemia as evidenced by blood glucose levels being maintained above 45 mg/dL, enhanced sucking ability, and appropriate weight gain. Interventions: Promoting Optimal Nutrition • Identify newborn at risk based on behavioral characteristics, body measurements, and gestational age to establish a baseline and allow for early detection. • Assess blood glucose levels as ordered to determine status and establish a baseline for interventions. • Obtain blood glucose measurements upon admission to nursery and every 1 to 2 hours as indicated to evaluate for changes. • Observe behavior for signs of low blood glucose to allow early identification. • Initiate early oral feedings or gavage feedings to maintain blood glucose levels. • If oral or gavage feedings aren’t tolerated, initiate an IV glucose infusion to aid in stabilizing blood glucose levels. • Assess skin for pallor and sweating to identify signs of hypoglycemia. • Assess neurologic status for tremors, seizures, jitteriness, and lethargy to identify further drops in blood glucose levels.

• Monitor weight daily for changes to determine effectiveness of feedings. • Maintain temperature using warmed blankets, radiant warmer, or warmed isolette to prevent heat loss and possible cold stress and reduce energy demands. • Monitor temperature to prevent cold stress resulting in decreased blood glucose levels. • Offer opportunities for nonnutritive sucking on premature-size pacifier to satisfy sucking needs. • Monitor for tolerance of oral feedings, including intake and output, to determine effectiveness. • Administer IV dextrose if newborn is symptomatic to raise blood glucose levels quickly. • Decrease energy requirements, including clustering care activities and providing rest periods, to conserve glucose and glycogen stores. • Inform parents about procedures and treatments, including rationale for frequent blood glucose levels, to help reduce their anxiety. Note the newborn’s Apgar score at 1 and 5 minutes. If after 15 seconds of tactile stimulation without effective respirations or an increase in heart rate above 100 bpm, the infant should be resuscitated (Yousaf, Hayat, & Afzal, 2015). Several diagnostic studies may be done to identify underlying etiologies. For example, a chest x-ray helps to identify structural abnormalities that might interfere with respirations. Blood studies may be done, such as cultures to rule out an infectious process, a toxicology screen to detect any maternal drugs in the newborn, and a metabolic screen to identify any metabolic conditions (Fanaroff & Fanaroff, 2014). Monitor vital signs continually, check blood glucose levels for hypoglycemia secondary to stress, and maintain a neutral thermal environment to promote energy conservation and minimize oxygen consumption. Resuscitating The Newborn. Any newborn can be born with asphyxia without warning. Approximately 10% of newborns require some assistance to begin breathing at birth. The aim of neonatal resuscitation is to prevent neonatal death and adverse long term neurodevelopmental sequelae associated with perinatal asphyxia. Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful newborn resuscitation. Have all

basic equipment immediately available and in working order. Ensure that the equipment is evaluated daily, and document its condition and any needed repairs. Box 23.2 lists the equipment needed for basic newborn resuscitation.

BOX 23.2 BASIC EQUIPMENT FOR NEWBORN RESUSCITATION • A wall vacuum suction apparatus • Infant size stethoscope • Pulse oximeter • Epinephrine • Volume expander intravenous fluids • A wall source or tank source of 100% oxygen with a flow meter • A neonatal self-inflating ventilation bag with correctly sized face masks • A selection of endotracheal tubes (2.5, 3.0, or 3.5 mm) with introducers • A laryngoscope with a small, straight blade and spare batteries and bulbs • Ampules of naloxone (Narcan) with syringes and needles • A wall clock to document timing of activities and events • A supply of disposable gloves in a variety of sizes for staff to use

Determine the need for resuscitation by performing a rapid assessment using the following three questions: 1. What is the newborn’s heart rate? 2. What is the gestational age of this newborn? 3. Is the newborn breathing or crying now? 4. Does the newborn have good muscle tone? If the answer to all questions is “yes,” then routine care is initiated: provide warmth, clear the airway, dry the newborn, and assess color. If the answer to any of these questions is “no,” the newborn should receive one or more of the following actions, according to this sequence: 1. Stabilization. Dry the newborn thoroughly with a warm towel; provide warmth by placing him or her under a radiant heater to prevent rapid heat loss through evaporation; position the head in a neutral position to open the

airway; clear the airway with a bulb syringe or suction catheter; and stimulate breathing. At times, handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. 2. Assess for breathing – bag the newborn if not breathing 3. Place pulse oximeter on newborn’s right hand to determine oxygen saturation 4. Ventilation if needed 5. Assess heart rate 6. Chest compressions if needed 7. Administration of epinephrine and/or volume expansion (Vali, Mathew, & Lakshminrusimha, 2015). The decision to progress from one set of actions to the next and the need for further resuscitative efforts is determined by the assessment of respirations, heart rate, and color (American Academy of Pediatrics [AAP] & American Heart Association [AHA], 2014). Nurses need to remember that preterm infants have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. They also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock related to small blood volume. Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. When performing newborn resuscitation, use the mnemonic “ABCDs” (airway, breathing, circulation, and drugs) to remember the sequence of steps (Box 23.3). Resuscitation measures are continued until the newborn has a pulse above 100 bpm, a good (healthy) cry, or good breathing efforts and a pink tongue. This last sign indicates a good oxygen supply to the brain. Effective ventilation is the key to successful neonatal resuscitation (AAP & AHA, 2014). Throughout the resuscitation period, keep the parents informed of what is happening to their newborn and what is being done and why. Provide support through this initial crisis. Once the newborn has been stabilized, encourage bonding by having them stroke, touch, and, when appropriate, hold the newborn.

BOX 23.3 ABCDS OF NEWBORN RESUSCITATION • Airway • Place infant’s head in “sniffing” position. • Suction mouth, then nose. • Suction trachea if meconium-stained and newborn is NOT vigorous (strong respiratory effort, good muscle tone, and heart rate >100 bpm). • Breathing • Use positive-pressure ventilation (PPV) for apnea, gasping, or pulse